What the client reports: symptoms, goals, changes since last visit, response to prior treatment, relevant functional complaints. Example: “Client reports right upper-back tightness after two days of desk work; 4/10 discomfort when turning right.”
What you observe/measure within scope: posture, gait, ROM result, visible swelling/color, palpation response, treatment performed. Avoid presenting subjective palpation impressions as proven pathology.
Your professional interpretation of the session information within massage scope. Keep it tied to treatment planning rather than medical diagnosis. Example: “Right cervical rotation limited by reported tightness; tolerated broad upper-back/neck work without neurological symptoms.”
What happens next: home-care education within scope, reassessment, future session focus, modifications, referral or follow-up. Example: “Reassess comfortable cervical rotation next visit; continue pressure within tolerance; client advised to seek medical evaluation for any new weakness/numbness.”
S: Client reports 4/10 upper-back tension after increased computer work, denies injury/numbness/tingling. Goal is easier head turning.
O: Comfortable right cervical rotation appears less than left. Increased tenderness reported with moderate pressure to right upper trapezius. Performed Swedish massage and gentle ROM within comfort.
A: Client tolerated session well; right rotation felt easier afterward by client report. No adverse response observed.
P: Reassess next visit. Continue goal-directed upper-back/neck work if presentation remains appropriate.
“Broke up adhesions.” “Released toxins.” “Diagnosed pinched nerve.” “Fixed scoliosis.” “Client was difficult.” Documentation should be objective, respectful, clinically useful and within scope.