Physical Therapy SOAP Note Template
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Looking for a physical therapy SOAP note template or SOAP note physical therapy examples? If you’re looking for help in answering the questions around how to write SOAP notes, you’re in the right place.
Below we’ll share a physical therapy SOAP note template.
What’s a SOAP notes template 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 using a physical therapy SOAP note template, the organized structure should help make it easier for you to document an encounter with a patient or client during a session in an efficient way.
SOAP 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.
Read on and we’ll share a physical therapy SOAP note template and SOAP note physical therapy examples.
Why use SOAP notes in physical therapy?
SOAP notes in physical therapy are a helpful 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.
SOAP note template physical therapy
We’ve provided a downloadable physical therapy SOAP note template here.
The APTA website provides these guidelines on what information to include when writing a SOAP note physical therapy example.
- 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 for physical therapists, 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.
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 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 a SOAP note physical therapy example 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 a 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 physical therapy examples
It may be helpful to see examples of physical therapy SOAP notes. So, here you go.
Example #1 – Orthopedic SOAP progress note
Subjective:
Pt reports she felt some low back soreness after her last treatment (6/10), but the soreness abated over the next 24 hours. Current Pain Scale 3/10 in low back with no numbness/tingling/pain in her R Lower extremity. Mild ache in her right buttock that gets worse with transitions (sit to stand and rolling in bed). She was able to walk for 40 minutes two times in the last week, and is able to tolerate work using her standing desk for 45 minute intervals. Feels like she is making good progress to care.
Objective:
Observations:
Pt’s posture improved: decreased posterior sway and genu recrovatum in static posture . Lumbar Flexion ROM at 75% with decreased Thoracic flexion. Lumbar extension 80% with no pain. Also able to disassociate lumbar from hip motion in Bent Knee Fall Out in hooklying to 50% External Rotation ROM of the hip. Tenderness at R distal SIJ over sacrotuberous ligament and backward sacral torsion is present. Trigger Point at R piriformis and Quadratus Lumborum on R side. Tension in R > L hamstring but negative sciatic neural tension test. Negative Scour Test on the R Hip.
Treatment: Manual therapy to correct BST of sacrum, PA glides at L5S1 for 30 seconds, 3 times, TP release at R piriformis and QL for 1 minute, 2 times. TPDN to Trigger points in Hamstring to release. Education and HEP: SLS for 30 sec holds, stair climbing up and down for 1 minute with proper mechanics (no hip hiking) and gait reeducation focused in equal step length for 30 feet.
Assessment:
Patient is at 75% progress toward rx goals with reduced SIJ dysfunction, radiculopathy in R LE and LBP. She is at 80% improvement with mechanics: gait, stairs, squats, lunges and standing at standing desk. (and other functional retraining). Compliant with HEP. Improved abdominal brace control at ⅘ MMT. Limitations still with core stabilization, dynamic movements and functional retraining, as well as MMT and ROM..
Plan:
Progress abdominal and gluteal stabilization, biomechanics, strength program, and return to sport training. Provided patient HEP to improve ROM, strength and stabilization and functional retraining for impairments that are still present. Recommend continuing physical therapy one time a week for three weeks and then reevaluate.
Example #2 – Inpatient SOAP progress note
Subjective:
Pt reports he has more confidence with transfers. Slept poorly last night with complaints of Knee Pain and Phantom Limb Pain. Pain is now at 2/10 this morning, but he notes this phantom limb pain can arise, especially when he is at rest and/or when fatigues. He notes he is “getting antsy” and ready to discharge from inpatient rehabilitation as soon as possible.
Objective:
Observations: Improved tolerance to standing with below the knee prosthesis for 2 minutes. 20% less hip Flexion and Abduction mechanics in static posture. Able to gait with prosthetic for 30 feet 2 times with walker, SBA. Hip flexor contracture reduced by 80%. Improved hip Abduction and Adduction MMT 4 out of 5.
Treatment: Manual Stretching to R hip flexors and external rotators for 2 minutes, 2 times. Posterior glides to R Hip capsule for 2 minutes 2 times. Strength Training Sidelying Hip Abduction and ER, prone hip extension and adduction, 15 reps, 3 sets each. Progressed to 5 inch Step Ups in parallel bars with SBA 10 times, 2 sets. Review donning prosthesis. Review transitions from sit to stand with prosthesis.
Assessment:
Pt able to don prosthesis independently. Able to transfer independently, Weakness of gluteus medius and maximus present, as well as contracture of R hip flexors. Still fall risk with gait with walker. Progressing well to full independence – 75%. He is not ready to discharge this week. Requires full comfort with his walker beforehand.
Plan:
Continue with gait, stair and mechanical retraining, as well as strengthening and mobilization to right LE. Improve tolerance to wearing BK prosthetic. Provided the patient with HEP and education to reduce impairments still present. Recommend continuing physical therapy one time per day for the next week and then reevaluate progress toward goals and plan for discharge.
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