How to Write a Physical Therapy SOAP Note
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Wondering how to write a physical therapy SOAP note or a physical therapy progress note? Or perhaps you’re searching for physical therapy daily note samples?
Any which way–you’re in the right place. A SOAP note for physical therapy is also known as a progress note or daily note.
Read on, and we’ll share examples below to help make it easier for you to write a physical therapy, SOAP note.
What’s a SOAP note for physical therapy?
The SOAP note is a common method of written documentation used throughout healthcare–by behavioral health professionals, occupational therapists, speech-language pathologists, and physical therapists.
When you write a physical therapy SOAP note, the organized structure allows you to document an encounter with a patient or client during a session in an efficient way.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
The structure of the SOAP note template provides a “checklist” that serves as a cognitive aid and index to record and retrieve needed information.
A SOAP note for physical therapy offers a framework for collecting and evaluating information gained during the patient visit. With the subjective and objective data collected, physical therapists can generate and test clinical hypotheses, differential diagnoses, and assess the patient’s progression toward their treatment goals.
Documenting each session is essential to achieving quality patient outcomes. According to the American Physical Therapy Association (APTA), “Solid documentation can demonstrate that you met or exceeded the standard of care and can help you mitigate risks.”
Physical therapy SOAP notes can allow for seamless communication between the patient’s entire care team, and they can help to identify changes in patient status and spot any red flags that may arise. The progress note can also help mitigate any legal and/or safety risks for both the patient and the provider.
Writing a SOAP note for physical therapy
The APTA website provides these general guidelines about information to include when writing a SOAP note for physical therapy:
- Self-report of the patient
- Details of the specific intervention provided
- Changes in patient status
- Progress toward stated goals
- Clinical reasoning
- Any adverse reactions
- Communication with other providers of care, the patient, and their family
Practice management systems and EHR software, such as SimplePractice, include physical therapy SOAP note templates built into the systems, so the process of creating and saving daily notes is easy and streamlined.
By utilizing the structured format of the SOAP note template, physical therapists have an efficient way to record, track, and organize information from each client session.
The framework of a SOAP note for physical therapy makes it easier for you to assess, diagnose and properly treat your patients, based on a thorough collection of data and information.
Physical therapy SOAP notes include four specific sections designed to provide a comprehensive illustration of the patient’s visit.
S=Subjective section
The subjective section of a SOAP note for physical therapy describes the patient’s subjective experience.
This section contains the patient’s current chief complaint, self report of their overall status, update of symptoms and functional activities, and response to previous treatment.
Specific types of subjective information to include:
- Chief complaint
- Pain scale
- Current symptoms
- What aggravates the symptoms
- What eases the symptoms
- Response to previous treatment and home exercise program (HEP)
- Patient’s functional status
- Patient’s perceived improvement
- Current level of activity and exercise
O=Objective section
The objective section of the physical therapy SOAP note documents the objective data collected during the patient encounter.
The information contained in this section should be measurable, quantifiable and fact-based, such as tests and measurements, interventions and treatment provided, and any other objective findings collected.
Specific types of objective data collected include (if applicable):
- Range of motion (ROM)
- Manual muscle testing (MMT)
- Neurological testing
- Posture and biomechanical testing
- Orthopedic special testing
- Vestibular testing
- Vital signs
- Women’s health testing
- Review of specific physician’s progress notes
- Review of diagnostics performed
- Treatment conducted in detail including exercise, manual therapy, modalities, patient education, all supported with specific details
A=Assessment section:
The assessment section of a SOAP note for physical therapy documents the synthesis of the subjective and objective information collected.
In this portion of the note, the therapist works through the diagnostic process, utilizing clinical decision-making and reasoning. The assessment section also describes the client’s progress toward their stated goals.
Specific components of the assessment section include:
- Differential diagnosis
- Professional assessment of patient progress
- Response to care and treatment
- Remaining impairments and functional limitations to address
- Safety issues, restrictions, and precautions
- Adjustments to established goals
P=Plan section:
The plan section of the physical therapy SOAP note details the treatment plan established to meet the stated goals.
According to APTA, “The physical therapist should provide specific information related to the plan for future services including patient/family/caregiver education and any possible changes in the treatment program. Do not simply say ‘continue.’”
This section can also include any adjustment to plan of care (POC), education, frequency and duration of care.
Specific components of the plan include:
- Plan for next visit
- Intervention progression
- HEP progression
- Patient education and recommendations
- Adjustments to the treatment plan
- Frequency and duration of patient visits
When these sections are completed, the physical therapist will have a comprehensive view of the individual patient encounter, as well as the overall picture of the patient’s treatment and progress.
At any time in the future, the therapist can look back at the patient’s progress notes and get a concise understanding and documentation of the patient’s clinical journey in physical therapy.
SOAP note or physical therapy daily note example
It may be helpful to see a physical therapy daily note example:
Subjective:
Jessie reports she has had difficulty sleeping on her left side because of left hip pain. She says the pain radiates from the side of the left hip to her knee - 5/10 on VAS. Pain is intermittent. Jessie also reports that she is also finding it difficult to run without immediate left hip and knee pain.
Objective:
Jessie runs with medial rotation and adduction with some navicular drop on left LE. Pain with both running or walking. Antalgic gait and positive trendelenburg gait pattern. She has point tenderness over the left greater in the left hip. Reduced left hip ROM - internal rotation 75% and external rotation 90% of normal limits. Presents with positive Thomas Test with abduction, and limited extension ROM by 20 degrees. Trigger points at left TFL and tension of left ITB.
Radiographs show some osteoarthritis on the lateral and inflammation over left trochanteric bursa. Did manual therapy and neurological reeducation with running and walking gait, as well as standing postural mechanics. Provided insoles for patient.
Assessment:
Differential diagnosis indicates that Jessie has trochanteric bursitis of the left hip. Jessie understands her HEP and education provided to improve FMP and reduce pain. She is motivated to get better and committed to her PT and home program.
Plan:
Recommend patient do physical therapy one time per week for 6 weeks, focused on manual therapy, education, HEP, reduction of inflammation and focus on faulty movement patterns. Reevaluation at 6 weeks to determine next steps.
Important tips for writing a SOAP note for physical therapy
In your SOAP notes, be sure to respect patient confidentiality. HIPAA Standards apply to ALL documentation in medicine.
Be concise and accurate in your documentation. And remember to be pragmatic in your assessment.
Avoid making general statements with no objective evidence.
Distinguish between symptoms and signs. Symptoms are the patient’s subjective description (to be included in the subjective section of the SOAP note), whereas signs are objective findings related to the associated symptom (to be included in the objective section of the SOAP note). Oftentimes, signs and symptoms are mistakenly used interchangeably in physical therapy.
Be aware of including your own subjective opinions and personal judgements in a patient’s note.
If your patient is not meeting the established goals, there is no need to entirely change the treatment plan. Instead, make any needed adjustments to the existing care plan to help your patient meet their goals.
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