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 that’s short 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 gathering of information, 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 the event of 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:
|Subjective||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.|
|Objective||Posture: right scapula abducted and internally rotated while sitting.
Lacks full upward rotation of scapula on active shoulder flexion.
|Assessment||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.|
|Plan||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.
Top Tip: try using voice transcription, which means no typing. You can easily get your notes out of your head and into your private practice software.
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.