Brief Explanation of Clinical Evaluations

Part of my massage therapy training is spending a minimum of 54 hours in the school's local clinic, offering massages at a student discounted rate. Due to my other college schedule and the considerable commute it would be to drive from Southfield to Ann Arbor on a school night, I've decided that I'm going to do my clinical hours during Thanksgiving and Christmas. At clinical orientation all of us were given a nice packet of information that included all the common medical abbreviations, the types of notes they use, evaluation sheets, and pretty much everything else that I'd need to prepare before I start my clinicals.

The clinic's notes are based on S.O.A.P (Subject information, Objective information, Assessment, and Plan) notes. For the extra-curious reader, here is the breakdown of what SOAP notes really are.

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Subject information is the client's needs and goals for the massage. This is a list of symptoms and analysis of the symptoms (onset, location, intensity, duration, frequency).

Objective information is the treatment goals. This can include the visual data from the client (posture, breathing, gait patterns, bruises, swelling, muscle guarding, tension) and observation after gathering some basic information from palpation (spasm, trigger points, tight muscles, scars, adhesions, joint ROM, muscle testing, tissue temperature, cranial rhythm, etc).

Assessment is the changes observed in a clients symptoms, function, musculature, mobility, and posture after massage treatment. This is also where I will indicate the therapeutic techniques used.

Plan refers to the future work needed. This may involve client "homework", which will vary greatly depending on the client; recommendations could range from lumbar stretches, applying heat/cold to indicated areas, or seeking medical advice from a doctor.
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I realize clinical evaluations will not be so readily accessible/interesting to the general public. But, in case anyone is interested, I will make all of the evaluations public and remove any and all confidential information that the client does not want to share. Important Note: if you receive a massage from me it does not automatically mean you will be featured on this blog. I will always ask permission before I post anything about anyone on this type of public forum.


If you've read this far, tune in later this week too! I plan to do the following:

- scan a reference list of abbreviated language
- report my first tentative practice clinical evaluation
- write an informative and (hopefully) interesting post on muscle stretches for cyclists!

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EDIT: I prefer calling the SOAP notes by Subjective, Observation, Assessment, and Plan. Better wording, imo.