SOAP Notes – Objective Section Guide
The Objective section of the SOAP note captures clinically observable data gathered by the provider through impartial, hands-on evaluation of the patient. This section varies between the first appointment and subsequent visits, and is critical in assessing changes in the patient’s condition over time.
🩺 First Appointment – Full Clinical Evaluation
During the initial visit of a referral, the Objective section includes a full structured evaluation guided by the Provider App.
🔍 App-Guided Objective Sections:
Posture Evaluation
Range of Motion (ROM)
Muscle Tone, Temperature, Inflammation, and Color
These questions are designed to capture a baseline of the patient's physical presentation and help inform clinical treatment goals.
✅ When to Complete:
This section must be completed before starting the massage session with the patient.
✏️ Editing Guidelines:
You can edit the Objective section during the appointment and even after the treatment is complete.
However, once you check out in the “Treatment & Checkout” section, the Objective section becomes locked and can no longer be changed.
🔁 Subsequent Appointments – Update Key Findings
From the second appointment onward, the Objective section becomes progress-focused and more streamlined.
🧠 What’s Different:
The system will carry over your initial objective findings from the first appointment.
You will be asked to update at least 3 findings, selecting whether each has:
Improved
Regressed
Remained unchanged
This change allows for a more efficient documentation process while still ensuring clinical accuracy.
📈 Benefits:
You’ll be able to view previous findings easily, helping track progress across appointments.
The structured format reduces documentation time while capturing meaningful clinical data.
Eliminates the need to retype clinical observations in free-text format.
🧠 Best Practices & Tips
Always review previous findings before making updates to ensure consistency.
Choose at least three relevant findings to assess and update at every follow-up session.
Remember to complete and save the Objective section before completing the appointment checkout to avoid being locked out of edits.
Use clear and objective observations; avoid assumptions or subjective interpretations.