The Art of the Chart
Documenting Massage Therapy with
By Mary Kathleen Rose
reading the massage therapists' CARE notes in the patients' charts.
They give me a good picture of what is going on with my patient."
are words spoken by a nurse who works in a hospice setting. They are
typical of comments made by several nurses and staff members of this
medical organization. “I am interested in what the massage therapist
thinks,” another nurse says. “The CARE notes documenting
the massage therapist’s visits with a patient can tell an interesting
story that assists me in determining the best care for that patient.”
What are CARE notes and how do they fulfill the requirements of documentation
in medical settings? How do they serve as a tool for communication between
different members of a medical staff? Do they fulfill the needs for
charting in other settings, such as rehabilitation, spas or long-term
care facilities? How are they useful to massage therapists in private
practice? Can CARE notes be used to chart massage sessions for which
insurance reimbursement is involved? This article addresses these questions
and looks at issues and concerns regarding charting for those in the
massage therapy profession.
When I was a massage student in 1984, we learned little about charting
for massage therapy. We were required to write about a certain number
of the sessions we gave as students, but the purpose of this was to
record details about the techniques we were learning. We also recorded
our thoughts and feelings in a manner that was more akin to writing
a personal journal.
In the mid-1980s, massage therapists began to work in chiropractors’
offices and do work for which they sought reimbursement from insurance
companies. This emphasized the need for charting, but most therapists
simply submitted written reports, which usually satisfied the needs
of the insurance companies. Later in the ‘80s some massage therapists
began to use the SOAP format to document their work. SOAP is an acronym
that stands for Subjective information, Objective information, Assessment
SOAP is a format initially used in physical therapy that has been adapted
and used widely by massage therapists. Variations of this charting system
have become part of the curriculum in a majority of massage schools
Issues and Concerns
In researching the use of SOAP charting by massage therapists, I discovered
a number of concerns with the format. Michelle Bowman, R.N., L.Ac.,
who is the Integrative Medicine Manager at Longmont United Hospital
in Colorado, says, “I don’t feel that SOAP charting is appropriate
for massage. It is not consistent from one therapist to the next.”
Bowman supervises a program which employs 13 massage therapists.
Michele Kolakowski, who is the lead massage therapist on the team, adds,
“There is no standardization for charting among massage schools.
It is even different now than when I went to school 12 years ago.”
The meanings and uses of the letters in SOAP vary from textbook to textbook
and from teacher to teacher.
Yet, as therapeutic massage becomes more accepted as a valuable treatment
in healthcare settings, the need for workable charting systems is imperative.
Bowman and her co-workers are working to develop new systems for charting.
She says they are also challenged to meet the requirements of the Joint
Commission on Accreditation of Healthcare Organizations. This accrediting
agency is particularly interested in documentation that can record the
status and changes in the levels of pain experienced by the patient
before and after receiving massage.
Kolakowski, who has extensive experience in perinatal massage, also
acknowledges the importance of charting, emphasizing reliable documentation
reflects on the quality of care for the patient. She emphasizes that
good charting promotes continuity of care and facilitates communication
among the various healthcare professionals.
I interviewed a number of massage therapists, asking them to identify
their issues and concerns with charting. Here are some of their comments:
“I am required to write SOAP notes for my clients who are receiving
insurance reimbursement. But I hate to write these notes. I like doing
the massage, but not writing the reports.”
“I’m not always sure what needs to be in a chart, and what
might not be necessary.”
“When I was in massage school, I learned to chart SOAP notes,
but I don’t use them in my private practice, so I wouldn’t
feel confident to use them if I had to.”
One massage therapist, with five years of experience as a physical therapy
assistant, says the SOAP format makes sense for physical therapy where
there are specific treatment goals, but that it didn’t seem relevant
in her work doing relaxation massage in spa-type settings. Have we been
using approaches that feel like hand-me-downs from other systems, not
Natural Way of Charting
It is possible to address these concerns and offer a format for documenting
massage that is easy for the massage therapist to learn and use, and
that meets the requirements of different organizations. The implementation
of CARE notes offers a solution that is based on a natural approach
to communication. This flexible guide allows for comprehensive detail
when it’s required. It also offers a simple format for concisely
recording a massage session.
The CARE note system is based on the use of the following categories
to guide the therapist in recording the session: C =condition of client;
A=action taken; R=response of client; E=evaluation. The first three
of these elements — C, A and R — provide the critical information
about a session. They provide a picture of the recipient of the massage,
what kind of work was done and how the individual responded to that
work. The fourth element — E — can be optional, but it allows
space to record overall observations, recommendations or questions that
arise from the session.
CARE notes are completed after the session. We will explore these elements
in more detail, but first it is necessary to look at the initial client
intake, which is recorded before the session.
An initial session with a client should begin with completion of an
intake form. Depending on your setting, these formats vary widely. If
you work in a medical setting or massage clinic, they will provide a
standard form or one will have already been completed for you to see.
Some medical settings do not give the massage therapist access to the
patient’s chart. Rather, they inform the therapist of specific
details: e.g., the patient’s diagnosis and current medical condition,
contraindications and/or cautions for massage as well as specific areas
of concern, or areas needing massage.
The intake form includes the client’s name, gender, birthdate
and session date. It also has space for: client’s contact information,
address and phone number; medical history and current health conditions;
other therapies and medications currently being used; lifestyle factors,
including occupation, exercise and diet; prior experience with massage;
and reasons for receiving massage now.
Once an initial intake is completed, the session can begin. Information
in the client intake constitutes the first part of the client record.
CARE notes are completed at the end of the first session and after every
subsequent session. Depending on the complexity of the client’s
condition, the treatment you give and their response to it, CARE notes
can be quite simple and concise or they can be more lengthy or extensive.
Information from the client intake or medical record forms the basis
for the first part of the CARE notes.
Condition of the client
This section of the chart records the current condition of the client.
It should give an accurate picture of the person in the present, and
answers the questions, “Who is the client?” and “How
is the client now?” This part should include a concise summary
of relevant medical information from the client intake form. It will
also list current conditions and complaints, areas of discomfort, pain
or tension, as well as emotional well-being or state of mind. It records
the clients’ reasons for wanting massage, and their goals or intentions
for the session.
This section can include a notation of physical and/or emotional discomfort
or pain before the session. For example, you can ask, “On a scale
of 1 to 10, with 10 being the worst, how would you describe the pain
you are feeling right now?” After the session, you would ask this
question again and record the answer in the response section of the
Example. Condition: Clara T, 55-year-old female, with a history of asthma,
chronic pain from cervical strain (due to a car accident in 1985), complains
of pain in the area of right trapezius, overall tension in back, from
shoulder to hip, more notable on right side. Intermittent pain in right
sciatic nerve at piriformis, refers down right posterior leg.
She works in sedentary job, commuting 40 minutes to and from work daily.
Minimal exercise. She has not received massage before. Interested in
pain relief and overall relaxation, even though she voiced doubt that
massage could be helpful.
Before session: physical pain or discomfort, 7 (0=none; 10=highest level);
emotional pain or discomfort, 8 (0=none; 10 =highest level).
This section of the chart records the type of massage given, the length
of hands-on treatment time and the positions in which the client was
situated (prone, supine, seated or side-lying). It includes a summary
of techniques used, and the parts of the body massaged.
Example. Action: I performed a full-body 60-minute massage. In prone
position, using a face cradle, with small bolsters under each knee,
used Swedish massage strokes (effleurage, petrissage, tapotement) and
compression on the muscles of the back, gluteal region and legs. Specific
compression and acupressure to erector spinae and motor points in piriformis.
In supine position with bolsters under the ankles, massage of neck and
shoulders, with specific acupressure to the belly of right trapezius.
Massage of arms, including range of motion, effleurage and petrissage
with arm extended overhead. General massage of anterior legs. Specific
reflexology to feet. Polarity hold of lower abdomen. Gentle rocking,
followed by general press of abdominal muscles. General work to head,
face and scalp. End with polarity hold of neck and forehead.
This section of the chart records the physiological changes noted during
and after the session. It includes the verbal feedback of the client,
as well as nonverbal responses. You can note changes in breathing, tonicity
of muscles, facial expressions or body positioning. This is also the
place to record changes on the pain scale if you are using that detail
of the chart. It can also be significant if there are no changes. Sometimes
the response of the client is not what we desire or anticipate. That
is OK. Record it anyway. Sometimes the client’s physiological
or verbal response will not match your observations. Record both. Remember
that human beings are very complex and we don’t always fully understand
what is happening.
Example. Response: The client was initially very inquisitive about the
work, but was quickly receptive to the touch. Throughout commented that
it felt good. Her breathing became slower and deeper. The areas of hypertonicity,
particularly the shoulder, back and gluteal areas, relaxed notably.
Some ticklishness in the feet, but responded positively to more broad
pressure there. She commented, “I didn’t know massage could
feel so good.” She said she particularly liked the work on the
scalp and face and that she would have liked that to have been longer.
After session: physical pain or discomfort, 2 (0=none; 10=highest level);
emotional pain or discomfort, 3 (0=none; 10=highest level).
This section provides a space to record the overall evaluation of the
session. It includes plans or expectations for subsequent sessions.
It may include any observation not already recorded. It contains any
recommendations made to the client. This could include encouragement
to breathe more deeply or a suggestion for a simple exercise to alleviate
back pain. If the client is being seen by other caregivers, this could
include suggestions or relevant information for them.
Example. Evaluation: Follow-up sessions are recommended once a week
or every other week. Follow-up on major areas of hypertonicity, allowing
more time for scalp and face work. Client has some difficulty breathing
in prone position after 10 to 15 minutes. Minimize time in this position
next session or try side-lying position instead. Encouraged client to
check posture while driving and while at work to minimize some of her
discomfort. Emphasized importance of using phone headset at work. (Possibly
make some ergonomic adjustments at work station.)
Guide to Concise Narrative Summary
The information presented here gives a complete picture of the client’s
condition, what you did and how they responded. This format tells a
story and, while it can be expanded to include more information, sometimes
it is necessary to record a more concise summary of the session. Given
the CARE note format as a guide, the same session could also be recorded
Clara T, a 55-year-old female, who works at sedentary job, reports pain
in her neck, right shoulder, back and buttocks. She experiences significant
emotional distress. I gave her a 60-minute full-body massage, using
techniques from Swedish massage, acupressure and polarity, with particular
attention to areas of greatest discomfort. Reflexology to the feet.
She was very receptive to her first experience of professional massage.
She particularly enjoyed the work on her face and scalp. I encourage
her to check and correct her posture throughout the day, to minimize
The act of writing CARE notes provides an opportunity to acknowledge
individual clients and validate the significance of your work. The notes
tell a story about one person’s effect upon another through the
application of skillful massage therapy. I feel it is a privilege to
read the charts I see. When I read the notes of the therapists I supervise
or the students I teach, I am also able to identify areas of concern
and communicate those issues for the benefit of client and therapist
Attorney Linda M. Herrick underscores the importance of charting, “As
an attorney who has worked both as insurance defense counsel and representing
plaintiffs who have suffered personal injuries, I believe CARE notes
charting offers concise, understandable information that will be useful
to all involved. I would like to see CARE notes as the standard for
massage therapy charting.”
Using CARE notes, we can let the same care and concern that governs
our hands-on work also inform the narratives we tell about these people.
With a system that is easy to follow, flexible and natural to use, we
take our place as healthcare professionals, able to communicate to others
this valuable work we do.
Beck, M.F. Milady’s Theory and Practice of Therapeutic Massage.
Milady Publishing; 1999.
Dunn, T., and Williams, M. Massage Therapy Guidelines for Hospital
and Home Care. Information for People; 2001.
Rose, M.K. The Gift of Touch — Comfort Touch: Massage for
the Elderly and the Chronically and Terminally Ill. Hospice of
Boulder County; 1996.
Salvo, S.G. Massage Therapy Principles and Practice. W.B. Saunders
Thompson, D.L. Hands Heal: Documentation for Massage Therapy —
A Guide to SOAP Charting. 1993.
Mary Kathleen Rose, C.M.T., has more than 25 years experience in
the holistic health field. She is the developer of Comfort Touch, a
style of massage appropriate for the elderly and ill. She supervises
the massage therapy program at HospiceCare of Boulder and Broomfield
Counties in Colorado, and teaches in various massage schools and medical
settings. She can be reached at 303/449-3945 or firstname.lastname@example.org.
for Using CARE Notes
are some things to think about when charting a massage session:
• Sign and date the chart. The massage
therapist’s name and signature, along with the date of the
session, should always be on the chart. The completed chart can
then be given to one’s supervisor or kept for personal records.
• Complete the chart as soon as possible after the
session. It’s easier to do while the experience
is fresh. With practice, it should only take a few minutes to
accurately complete all the details necessary.
• Keep in mind the person(s) who will read the chart.
In the hospice organization where I work, the notes go in the
patient’s permanent record, but they are also read by several
other people, including the nurse, the social worker, the volunteer
coordinator and the massage therapy supervisor. In other settings
or circumstances your notes could be read by other professionals
including physicians, physical therapists, chiropractors, attorneys
or insurance claims personnel.
• Use precise and correct medical terminology.
Avoid vague or imprecise terms. It is best to use correct medical
terminology whenever possible. For example, “I massaged
her stomach.” You probably mean to say, “I massaged
her abdominal region.” Also, be careful of intangible words
like “energy” or “energy work.” For a
medical record or a chart that will be read by someone working
for an insurance company, it is best to use words that describe
exact anatomy, physiological responses or specific techniques
of bodywork. Of course, much of what happens in a massage therapy
session is intangible or difficult to describe. Don’t worry
about it. Just record what you can, keeping your audience in mind.
If you are not sure your notes are adequate or appropriate, ask
your supervisor or someone else who reads them.
• Be aware of legal ramifications. When
charting for insurance purposes, it is important to document levels
of physical and emotional pain and suffering. If the client is
being reimbursed for massage as part of basic personal injury
protection coverages, document these sessions carefully. Record
the work you do and changes in the client’s condition relevant
to the injury for which they are being compensated. Do not speculate
about prior injuries or conditions.
• These records are confidential. Notes
are to be read only by authorized people who are involved in the
patient’s care. They should be kept in a safe place where
protected from anyone else’s view.
• Keep in mind your scope of practice.
Be consistent with your role as a massage therapist. You can make
observations of the client, but you can not diagnose a condition.
For example “anxiety” is a medical diagnosis. You
can report when the client says, “I feel stressed out.”
If you are trained in other aspects of health education you may
draw on that awareness. For example, you might suggest an exercise
that can benefit the client, that they can practice to augment
the benefit of the massage session.
• Avoid judgment. You can present the facts
as you see them, but avoid interpretations. As a massage therapist
you often receive information that no one else on the client’s
care team has, so it is important to report those observations.
• Be careful with abbreviations and use of symbols.
Keep in mind that the point of charting is to record the session
and communicate it with others when necessary. The use of abbreviations
can be useful to expedite charting, but be sure that everyone
reading the chart knows what the abbreviations mean. (One supervisor
was alarmed to find the letters S.O.B. in the chart of a frail
85-year-old woman, until she realized that the letters meant “shortness
of breath.”) Find lists of accepted abbreviations for the
facility where you work. You can refer to Hands Heal by Diana
Thompson or a medical dictionary.
• You may use sentence fragments. It is
okay to use fragments to save time and space when charting, but
make sure they make sense to the reader. The test of an adequate
sentence fragment is this: Can the reader easily translate that
fragment into a logical sentence that would be consistent with
the flow of the information in the chart? For example, “Intermittent
pain in right sciatic nerve” can easily
be understood as, “The client reports intermittent pain
in the right sciatic nerve.”
• Write legibly. A chart that cannot be
read is worthless. More people are typing now and plans are underway
in various facilities to computerize charting. Nurses and physical
therapists are already using new programs for medical charting.
• Keep a personal journal of your work.
Often you will be the only person to read your CARE notes, particularly
if they are notes you keep for your private practice. Even so,
they can be a valuable reference from session to session. After
an initial session, subsequent sessions can often be recorded
very concisely. Along with the elements of a CARE note chart,
you may also find it worthwhile to record your personal experience
(maybe under the “E” section of the CARE notes). I
encourage all of my students to do this. It gives them a place
to record questions and concerns and to assess their own level
of confidence with the techniques they are learning. Charting
can also bring a sense of closure to the massage therapy session.
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