Low back syndrome secondary to postural changes due to prolonged work at a computer desk. Physical examination reveals tightness in lumbar paraspinal muscles bilaterally as well as some localized tender points on palpation of lumbar erectors bilaterally, especially on the left side. He reports that he has had low back pain for several years but now it is increasing in intensity with little relief from over-the-counter medications or rest. The patient is a 45-year-old male complaining of chronic low back pain radiating into both buttocks and legs. Example 2: Low Back Pain radiating Subjective: The patient will have continued massage therapy with a focus on relieving muscular tension and improving the range of motion in the affected area. The patient is likely experiencing acute lower back pain due to muscular tension or spasms. The patient reported 4/10 pain intensity and increased it to 6/10 after tissue manipulation. Objective:ĭuring the massage, the patient’s lower back was tender to palpation and he exhibited guarding behaviour when certain areas were touched. He reports having a dull ache that radiates down his right leg at times, and he has difficulty standing upright or bending forward due to the pain. The patient is a 40-year-old male who has been experiencing acute lower back pain for the past 3 days. We will also discuss the benefits of using soap notes and how they can help improve your treatment outcomes! Example 1: Acute Back Pain Subjective:
In this blog post, we will provide five examples of SOAP note templates that you can use in your own practice. In order to make sure you're providing the most accurate information, it's essential to have a strong understanding of what should be included in your soap notes. As a massage therapist, you know that providing clear and concise soap notes is essential for effective communication with other health professionals. They allow you to document your treatment plans, track patient progress, and more. SOAP notes are a critical part of the massage therapy process.
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