Client Assessment & Treatment Planning
This chapter covers gathering client information, evaluating findings, and building a safe, individualized treatment plan. Good assessment underpins effective and ethical practice.
Health Intake and Interview
The pre-session intake gathers health history, current concerns, and goals in order to screen for contraindications and tailor the session. Massage therapists gather information to work safely within scope; they do not diagnose medical conditions.
Subjective and Objective Findings
Subjective data is what the client reports, such as a pain rating of eight out of ten. Objective data is what the therapist observes or measures, such as posture, range of motion, or palpable tissue tension. Both inform the plan and should be documented accurately.
SOAP Documentation and Planning
Many therapists chart with SOAP notes: Subjective, Objective, Assessment, and Plan. Clear records support continuity of care, communication with other providers, and appropriate treatment planning, including reassessment of progress over time.