It was nearly 9 p.m. a wellness coach sat alone, flipping through notes from the day. Paper sheets folded in half, others creased and coffee-stained, some scribbled so fast they barely made sense.
One client had mentioned fatigue. Another had a shoulder issue. One had reacted to a product, but was it the serum or the scrub?
There were six sessions that day. Six conversations. Six different problems and plans. But none of it was clear anymore. She tried remembering, digging into memory, comparing notes across two notebooks and a calendar app.
The notekeeping was obviously a disaster, which became abundantly clear when the boss asked for a quick update on some recent client histories; the wellness coach could only make guesses from half-remembered conversations.
That is where SOAP notes, when combined with a smart CRM, can completely shift the way you work. There are many reasons why good note-taking makes a big difference.
Apart from making you look much better when someone senior wants to track the progress of any particular client, they can also play a vital part in any legal, insurance, and compliance situations.
In many states, therapists are required by law to keep professional documentation. Soap notes are an ideal way to do all this. Consistent SOAP documentation gives your business backbone and shows you’re an evidence-based professional.
“Consistent SOAP notes underline the fact you’re an
evidence-based professional.”
– Attributed by Dr. Lawrence Weed, developer of the Problem-Oriented Medical Record.
Today, SOAP notes are widely adopted across healthcare and wellness fields, not just to track symptoms, but to create a clear, ongoing narrative for each client’s care.
What are SOAP notes?
SOAP notes are a structure for health and wellness professionals to follow that keeps everything in a consistent, logical flow. And done well, they can be more than this. They are also great for tracking a client’s journey. What improved, what didn’t, and where to go next.
The concept of SOAP notes was originally created by Dr. Lawrence Weed, the physician who developed the Problem-Oriented Medical Record (POMR) in the 1960s. SOAP, standing for Subjective, Objective, Assessment, and Plan, was introduced as part of this system to help practitioners organize client data in a consistent and meaningful way.
In an interview published in The Permanente Journal, Dr. Weed reflected on the early days of his groundbreaking work. He observed that while scientists in a lab could focus on “one problem at a time,” physicians faced the challenge of “meeting many problems simultaneously.”
This realization led him to create a structured approach, allowing medical professionals to function with scientific rigor even amidst complexity. As he put it, “The POMR enables a highly organized approach to that complexity.” This disciplined method ensures that all client concerns are systematically addressed, leading to more comprehensive and effective care.
Here’s what the letters in SOAP mean, and how to work with the respective ideas.
S – Subjective
This section captures the client’s personal experience, symptoms, and verbal descriptions.
Example: “My shoulder hurts” or rating pain as 10/10.
Details: Pain type (dull, sharp, burning), intensity (1–10), and pattern (constant, intermittent). Typically self-reported by the client.
O – Objective
This includes measurable and observable data collected by the therapist or external sources.
Examples: MRI reports, height measurements, postural observations.
Details: Notes on spine alignment (lordosis, kyphosis), pelvic tilt, or visible inflammation. Avoid vague language, and ensure your notes are clearly written or typed, whether using paper, tablets, or electronic records. Ambiguous directions like “up here” or “there” aren’t acceptable.
A – Assessment
A professional summary of the session findings and treatment provided.
Details: Includes treatment type (e.g., deep tissue), body areas treated, and client response (e.g., tenderness, redness).
Important: Therapists should not diagnose, refer serious cases (e.g., suspected injury) to a medical professional.
P – Plan
Outlines the treatment strategy and client care recommendations moving forward.
Details: Suggested frequency and duration of sessions, therapeutic goals, and any home-care advice.
Note: Follow any relevant doctor’s recommendations and tailor the plan to whether the client seeks therapeutic or relaxation-focused treatment.
| 🔗 Want to see a real SOAP Note template? Click here to download a printable SOAP Note form (PDF) from AMTA to guide your session documentation. |
Notes are for when things are going well, too.
Let’s suppose you finish a massage session and jot a few things down on paper. Nothing too detailed, just enough to jog your memory later.
A week goes by. The client returns. They ask, “Can you do the same thing you did last time?”
With the right notes in place, this becomes a no-brainer. Without the right SOAP notes, follow-ups take time and guesswork.
For those working as a team, SOAP notes are particularly useful because they allow different people to take over the same client in a seamless way.
How SOAP notes and CRM work together
When SOAP notes live inside a CRM-connected system, they become more than just records. They become powerful tools for insight and growth. Each note is automatically tied to key client data like appointment history, past feedback, purchase behaviour, messages and follow-ups.
That means you don’t just see a session, you see the full story. You will instantly know how many sessions a client has completed, what worked (and what didn’t), and exactly what needs to happen next, all in one place.
| 💡 Want to dive deeper into how CRM helps boost client retention and streamline communication in massage therapy? Check out our blog on using CRM to improve client loyalty. |
More benefits you might not expect
Beyond the basics, SOAP notes unlock hidden advantages that can elevate your entire practice. Here are a few you might not see coming:
- Consistency that builds trust: Clients feel safe when you remember what they told you. Consistent records prove you are reliable.
- Better recall and confidence: No more flipping through five different sources. You will always walk into a session knowing exactly what happened last time.
- Smarter team collaboration: With SOAP notes visible in your CRM, team members can align their care. Everyone is on the same page, even if staff changes.
- Legal and ethical support: Timestamped, secure notes give you clear backup in case of questions, complaints, or audits.
- Long-term tracking: Want to see how many clients reported stress-related tension in the last 3 months? If your notes are structured and stored digitally, that is just a few clicks away.
What’s the bigger picture? A business that runs smarter
Structured SOAP notes are not just a feature. They are a foundation for modern wellness businesses. When they are linked to a smart CRM, you can:
- Automate follow-ups.
- See who is progressing.
- Identify client drop-off points.
- Personalize offers and care plans.
- Understand which treatments work.
All of this helps you grow your business, boost client satisfaction, and reduce burnout, without working longer hours.
| 📌 Pro Tip: Turn your SOAP notes into action triggers. Add simple tags like “improved”, “needs follow-up”, or “drop-off risk” to spark automated messages, rebooking reminders, or custom care plans, without lifting a finger. |
What’s coming soon
A robust wellness platform, Wellyx, will soon release built-in SOAP notes that connect directly with CRM, client profiles, appointments, communication logs, and marketing insights.
If you would like to be part of our testing program, why not call Rebecca Yousaf on our helpline?