SOAP notes are a simple yet effective way to document your client’s progress and maintain communication between yourself and other physios.
They record the entire process of a physical therapist interacting with a patient and have the advantage of their widespread adoption: almost all healthcare professionals are familiar with them.
What’s more, physical therapy SOAP notes help fulfil your legal obligations regarding patient documentation for insurance purposes.
So if you’re just setting up a physio practice or want to hone your note-writing skills, we explain the important function of SOAP notes in physical therapy and how to write your own.
What is a SOAP Note in Physical Therapy?
SOAP is an acronym for Subjective, Objective, Assessment, and Plan.
A physical therapy SOAP note is entered into a patient’s medical record to chronicle each episode of care, share information with other healthcare providers, and inform the clinical reasoning process.
The note should log the initial information gathering, generate a hypothesis about care, and decide on an optimal diagnosis and care plan based on the collected information.
Writing notes after each session and storing them in a GDPR-compliant system is essential for the safety and protection of your clients – and yourself – in an emergency or litigation. If you haven’t recorded it, it didn’t happen!
They can then serve as a refresher for physiotherapists with a heavy caseload who might struggle to remember details from the last therapy session.
In a nutshell, these documents effectively chronicle patient intake to patient discharge.
How Do You Write a SOAP Note for Physical Therapy?
The best way to write effective and reliable SOAP notes is to use a template, either created by yourself or using one already available in a practice management system for physiotherapists.
If you’re worried that SOAP charting will take time away from patient care, don’t be. It’s quite easy to do.
A physical therapy SOAP note is divided into four sections – Subjective, Objective, Assessment, and Plan. Here are the four sections and their functions:
As the name implies, ‘Subjective’ describes the first section in a SOAP note influenced by the patient’s unique feelings and experiences. The information recorded here could include;
- How they feel the physio treatment is progressing
- What their function level is and how it’s changing
- How their quality of life is evolving
- Why or how they will overcome their condition.
In this section, you should include relevant medical information from the patient’s chart and any relevant information from the family or caregivers. This is also a place to ask about the client’s goals.
The ‘Objective’ in SOAP notes is the direct opposite of the Subjective and should only contain measurable observations.
Performance-based and clinician-reported measures can be included here to analyse patient progression. An Objective section provides a physical therapist’s unbiased observations, including
- Activity limitations
- Participation restriction
- Functional and structural impairments of the body.
An Objective section should include enough detail that another provider, such as a physical therapist assistant or GP, can pick up where the SOAP note left off.
The ‘Assessment’ in SOAP notes describes how the physical therapist came up with the treatment plan.
This section fulfils your legal obligation to document patient progress, especially regarding insurance compliance. Assessments explain the reasoning behind diagnosis and treatment and capture the analytical thinking that powered the problem-solving process:
- The ultimate goals of physio treatment
- The influence of subjective and objective findings on treatment
- The best treatment for each patient’s unique condition
- How to resolve factors affecting treatment goals
As a therapist records their professional opinion about each session, notes in the Assessment section should expand with each episode of care. Any positive or adverse responses to treatment should be included here, too.
Finally, the three pieces above come together to inform a ‘Plan’.
A treatment plan should include exercises provided during the session, their justifications, the patient’s response, next steps and appointments, follow-up instructions, and outcome measurements.
You could add the following questions to your template:
- When will you see the client again?
- During that time, what are their plans?
- Are safety plans necessary?
- Have their goals changed?
A plan section should also contain recommendations for future care or referrals to other healthcare professionals. In SOAP charting, never use vague descriptions of treatment protocols, as this can confuse other providers.
Physiotherapy SOAP Note Example
If you’re anything like us, you’ll find it easier to learn through examples and trying the process yourself rather than reading about how it works.
Here’s a SOAP note example to make things a little clearer:
|The patient reports difficulty sleeping on his side due to shoulder pain. He presents today with 4/10 pain along the left biceps. Reaching behind his back to tuck in his shirt has become easier over the past week.
|Posture: right scapula abducted and internally rotated while sitting.
Lacks full upward rotation of scapula on active shoulder flexion.
|The patient demonstrated an improved ability to reach overhead with 2# weight. Further strengthening of the serratus anterior should aid in the precise motion of the GHJ to avoid impingement.
|Progress with increased resistance bands for standing exercises. Review progress in 4 weeks.
Prioritising Your Physical Therapy SOAP Notes
You didn’t become a physiotherapist to write notes. But even if you feel like you don’t have enough time to take notes, don’t ignore this part of your job.
You should take professional notes after every session for the following reasons:
- Safety of clients – keeping the rest of the team informed
- Your actions will be documented legally if your competence is questioned
- If you don’t take notes, you may not remember details from previous sessions or the client’s goals. When you ask clients to retell details or forget their goals, you will hurt the relationship you have built with them
- By avoiding writing client notes, you will only have to do so later, increasing your workload.
You’ll build better relationships with clients and make them feel appreciated by including social details like job titles and family information. You can also offer appropriate support if necessary if you include their mobility status in notes.
Using SOAP Notes Templates in Your Physical Therapy Practice
When writing physio SOAP notes, use a well-crafted template. You won’t forget anything and will be prompted to record what you need. You can save templates for common conditions you regularly treat, such as shoulder laberal tear advice and exercises.
You’ll also be able to keep your notes consistent and share them with other clinicians in your practice.
WriteUpp is a tailor-made practice management software for physiotherapists. It comes with 22 physical-therapy-specific note and assessment templates, including SOAP, the Lower Extremity Functional Scale (LEFS), the MSK Initial, and the Patient Reported Outcome Measure form.
Using software like this will mean you can write and access your physiotherapy notes from anywhere, using any device. It’s also GDPR compliant and ISO27001 registered, so you can rest easy knowing your notes are stored safely.
Sign up for a free trial, and you’ll have instant access to the library of assessment templates and a host of time-saving features to provide better care for your clients.
If you have any questions or want to chat about what an integrated practice management solution could do for you and your physiotherapy practice, just grab us for a live chat!
The button is just there in the bottom right corner of your screen.
SOAP Note FAQs
How do you write a SOAP therapy note?
Writing a SOAP therapy note follows a specific format to ensure clear and concise documentation of the session. The SOAP note stands for Subjective, Objective, Assessment, and Plan. Here’s a breakdown of each section and what to include:
- Subjective (S):
- Begin with the client’s identifying information, including their name, age, and relevant background details.
- Note the date and time of the session.
- Document the client’s subjective account of their current concerns, symptoms, emotions, and any other relevant information they share. Use quotation marks to indicate direct quotes from the client.
- Include any information about the client’s progress since the last session or any updates on their personal circumstances.
- Objective (O):
- Provide an objective description of the therapy session, including observations, measurable data, and the therapist’s impressions.
- Mention the client’s behavior, mood, body language, and any notable changes or improvements observed during the session.
- Include any assessments or tests conducted during the session and their results.
- Document any relevant information discussed or learned during the session, such as coping strategies, insights gained, or new skills practiced.
- Assessment (A):
- Summarize your professional assessment and analysis based on the subjective and objective information provided.
- Interpret the client’s progress, strengths, challenges, or any patterns observed.
- Identify any diagnosis or potential diagnosis based on your assessment, if applicable.
- Consider including any relevant theoretical frameworks or therapeutic models used to guide your assessment.
- Plan (P):
- Outline the plan for future therapy sessions based on your assessment.
- Specify the goals and objectives for the client’s treatment.
- Describe the interventions, techniques, or approaches you plan to use in future sessions.
- Include any referrals or recommendations for additional resources or professionals, if necessary.
- Note any homework assignments or self-care strategies you assign to the client.
- Mention the date and time of the next scheduled session, if applicable.
Remember to maintain client confidentiality and adhere to the ethical guidelines and regulations governing your profession while documenting therapy notes. It is important to use clear and concise language, avoiding jargon or technical terms that the client may not understand.
How do you write a SOAP note example?
Here’s an example of a SOAP note for a therapy session:
- Client: John Doe
- Age: 35
- Date and Time: June 7, 2023, 10:00 AM
- Subjective report: “Client stated feeling overwhelmed with work and family responsibilities. He mentioned increased irritability and difficulty sleeping. John expressed frustration with his lack of progress in managing stress.”
- Client appeared tense throughout the session, displaying fidgeting behaviour.
- Client’s effect was subdued, and he made frequent sighs.
- John reported sleeping an average of 5 hours per night for the past week.
- Assessed the client’s blood pressure, which was within normal range.
- Discussed stress management techniques and practised deep breathing exercises.
- Based on the subjective and objective information, it appears that John is experiencing high stress levels, resulting in irritability and disrupted sleep patterns.
- There is a need to address the underlying causes of stress and develop coping strategies to improve John’s well-being.
- In the next session, continue exploring the sources of stress and work on stress management techniques, such as progressive muscle relaxation.
- Assign John a daily journaling exercise to track stressors and emotions.
- Recommend that John engages in regular physical activity to promote better sleep.
- Provide educational resources on stress reduction techniques.
- Schedule the next therapy session for June 14, 2023, at 10:00 AM.
Please note that this is a generalised example, and the content and structure of a SOAP note may vary depending on the therapist’s preferences and the client’s specific needs.
What do you write in a physical therapy assessment?
In a physical therapy assessment, you document the client’s initial evaluation, including their medical history, current condition, physical examination findings, and your professional analysis. Here are some key elements to include in a physical therapy assessment:
- Client’s name, age, gender, and contact information.
- Date of assessment.
- Referring physician or healthcare provider, if applicable.
- A brief description of the client’s main reason for seeking physical therapy.
- Document the client’s specific symptoms or functional limitations.
- Document the client’s relevant medical history, including past injuries, surgeries, or medical conditions.
- Note any medications the client is currently taking.
- Gather information directly from the client about their subjective experience of their condition, including pain levels, location, duration, and aggravating or relieving factors.
- Ask about their functional limitations, goals, and expectations for therapy.
- Perform a comprehensive physical examination, including relevant tests and measures based on the client’s condition.
- Document objective data such as range of motion, strength, joint stability, posture, gait analysis, and any specific assessments or tests performed.
- Include measurements of relevant body parts, such as circumference or length discrepancies.
Assessment and Analysis:
- Summarize your professional analysis of the client’s condition, based on the subjective and objective information.
- Identify any impairments, functional limitations, or potential diagnoses.
- Discuss any contributing factors to the client’s condition, such as biomechanical issues, muscle imbalances, or postural abnormalities.
- Consider the impact of the client’s condition on their activities of daily living (ADLs), work, or sports performance.
- Collaboratively establish functional goals with the client.
- Specify the short-term and long-term goals for the therapy sessions.
- Ensure that the goals are measurable and achievable within a reasonable timeframe.
- Outline the treatment plan based on the assessment and goals.
- Describe the treatment techniques, modalities, exercises, or interventions you plan to use.
- Mention the frequency and duration of therapy sessions.
- Consider any necessary referrals to other healthcare professionals or additional tests.
Remember to maintain client confidentiality and adhere to the ethical guidelines and regulations governing physical therapy while documenting assessment notes. Use clear and concise language, avoiding jargon or technical terms that the client may not understand.
What is the SOAP note format?
The SOAP note format is a structured method of documenting patient or client encounters in various healthcare settings. It provides a systematic and organized approach to documenting information. The SOAP acronym stands for Subjective, Objective, Assessment, and Plan. Here’s a breakdown of each section in the SOAP note format:
- This section includes the client’s subjective information, such as their chief complaint, symptoms, feelings, and perceptions.
- Document the client’s self-reported information in their own words, using quotation marks for direct quotes.
- Include relevant details about the client’s medical history, past treatments, or any other information they provide.
- The objective section consists of observable and measurable data gathered during the assessment or examination.
- Include information such as vital signs, physical examination findings, test results, and any relevant measurements or observations.
- Provide an objective description of the client’s physical appearance, behavior, and any relevant clinical findings.
- In this section, the healthcare provider or therapist offers their professional assessment and analysis based on the subjective and objective information.
- Summarize the client’s condition, diagnosis (if available), and any identified problems or issues.
- Include interpretations of test results, clinical impressions, and any relevant differential diagnoses to consider.
- The plan section outlines the recommended or proposed plan of action based on the assessment.
- Specify the treatment plan, including interventions, therapies, medications, or procedures to be employed.
- Outline any further diagnostic tests, consultations, or referrals deemed necessary.
- Include instructions for the client’s self-care, follow-up appointments, or home exercises.
- Mention any education or counseling provided to the client.
- Establish a timeline or schedule for future appointments or interventions.
The SOAP note format is widely used in various healthcare disciplines, including medicine, nursing, physical therapy, occupational therapy, and psychology. It helps to ensure comprehensive and consistent documentation while promoting effective communication between healthcare providers.
What is the fastest way to write a SOAP note?
While writing a SOAP note requires attention to detail and accuracy, there are a few strategies you can use to streamline the process and write SOAP notes more efficiently. Here are some tips to help you write SOAP notes faster:
- Use Templates: Create or find pre-designed SOAP note templates that include the necessary sections and headings. Having a template ready can save time by providing a structure to follow, allowing you to fill in the specific details for each client quickly.
- Utilize Technology: Take advantage of electronic health record (EHR) systems or note-taking software that offer built-in SOAP note templates. These tools often include features such as auto-fill options, checkboxes, and dropdown menus, which can expedite the note-writing process.
- Use Abbreviations and Standardized Phrases: Develop a list of commonly used abbreviations and phrases that are specific to your practice or discipline. This can help you quickly document repetitive information and save time while maintaining accuracy.
- Be Concise: Focus on capturing essential information and avoid unnecessary details. Use clear and concise language to communicate your findings and recommendations effectively.
- Prioritize Key Information: Identify the most important information that needs to be documented in each section of the SOAP note. By prioritizing critical details, you can streamline the process and avoid spending unnecessary time on less significant information.
- Document as You Go: Try to document information in real-time during the session or examination. This approach allows you to capture details while they are fresh in your mind, reducing the risk of omitting important information later on.
- Practice Efficient Note-Taking: Develop a system or shorthand technique that works for you to take notes quickly during the session. This can include using abbreviations, symbols, or bullet points to capture key information, which can later be expanded into full sentences or paragraphs when writing the SOAP note.
Remember that while speed is important, accuracy and completeness should not be compromised. It is essential to ensure that your SOAP notes are comprehensive, clear, and aligned with professional standards and legal requirements.
What should a SOAP note include?
A SOAP note should include the following components:
- Client’s identifying information, such as name, age, and relevant background details.
- Date and time of the session.
- Client’s subjective account of their current concerns, symptoms, emotions, and any relevant information they share.
- Updates on the client’s progress since the last session or any changes in their personal circumstances.
- Objective observations made during the session, including the client’s behavior, mood, body language, and any notable changes or improvements observed.
- Results of assessments, tests, or measurements conducted during the session.
- Information discussed or learned during the session, such as coping strategies, insights gained, or new skills practiced.
- Professional assessment and analysis based on the subjective and objective information.
- Interpretation of the client’s progress, strengths, challenges, or any patterns observed.
- Identification of any diagnosis or potential diagnosis, if applicable.
- Consideration of relevant theoretical frameworks or therapeutic models used to guide the assessment.
- Plan for future therapy sessions based on the assessment.
- Goals and objectives for the client’s treatment.
- Interventions, techniques, or approaches to be used in future sessions.
- Referrals or recommendations for additional resources or professionals, if necessary.
- Homework assignments or self-care strategies assigned to the client.
- Date and time of the next scheduled session, if applicable.
It’s important to maintain client confidentiality and adhere to ethical guidelines and regulations while documenting SOAP notes. Use clear and concise language, avoiding jargon or technical terms that the client may not understand. Additionally, tailor the content and level of detail to meet the specific needs of the client and the requirements of your practice or profession.
How long should a SOAP note be?
The length of a SOAP note can vary depending on several factors, including the client’s condition, the complexity of the session, and the requirements of your practice or organization. While there is no fixed length, it’s generally recommended to aim for concise and focused SOAP notes that capture the necessary information.
SOAP notes should provide enough detail to accurately document the client’s condition, progress, and treatment plan, but they should also be clear and concise for easy readability and effective communication among healthcare providers. Avoid unnecessary repetitions or irrelevant information that does not contribute to the client’s care.
As a general guideline, a SOAP note should typically range from a few paragraphs to a page or two. However, it’s important to prioritize completeness and accuracy over strict adherence to a specific length. Focus on including the relevant subjective and objective information, a well-considered assessment, and a detailed plan for treatment.
It’s also worth noting that some healthcare settings or organizations may have specific requirements or templates for SOAP notes, which can influence the expected length. Always follow the guidelines and standards set by your practice, institution, or regulatory bodies to ensure compliance and consistency in your documentation.