Physical therapy (abbreviated as PT) is a profession dedicated to the assessment, prevention, and rehabilitation of physical injuries, mobility, conditions, and disabilities of individuals.
It utilizes various methodologies and techniques, such as physical exercises and manual therapies, to restore physical movement or function, alleviate pain, and enhance the overall well-being of patients. Effective communication and documentation are at the core of providing optimal patient care. This can be achieved through a SOAP note. Physical therapists or their assistants use it to accurately assess, treat, and monitor patients’ daily evolution or initial progress. As a result, this information steers the path toward recovery and an enhanced quality of life.
This article explores the vital role of SOAP notes in physical therapy. It will highlight the key information included in such a note by discussing its fundamental components. Also, it provides you with best practices for writing a note to ensure you provide better patient care. You can reference the examples we have provided to understand how to structure a SOAP note as a professional in the physical therapy field. The examples are easy to comprehend and readily customizable to simplify creating patient-specific notes.
What is a Physical Therapy SOAP Note?
A physical therapy SOAP note is a structured and organized documentation tool you use to record a patient’s information, assess their condition, and monitor their progress during the course of the treatment.
The acronym “SOAP” stands for Subjective, Objective, Assessment, and Plan, representing the four key sections of this note. It can be used by physical therapists, assistants, and other healthcare specialists.
The subjective section documents information the patient and their caregiver provide, such as their medical history, symptoms, complaints, and physical therapy preferences and goals. On the other hand, the objective section focuses on measurable (quantifiable) and observable data, such as physical test results, test outcomes, vital signs, range of motion measurements, etc. The assessment part records your professional judgment on the patient’s condition based on available subjective and objective data regarding the patient’s condition and care. In this section, you can outline the diagnosis, progress evaluation, and changes in their status since their last visit. Finally, the plan section outlines the proposed course of action for the patient’s rehabilitation or recovery. This includes the immediate and long-term goals, modalities, treatment frequencies, and specific exercises incorporated into the patient-specific strategies, interventions, and treatment plans.
Free Templates
Information to be Included in a Physical Therapy SOAP Note
The SOAP note provides a holistic and comprehensive view of the patient’s condition and care. As such, it will let you document the patient’s self-report, diagnosis, interventions, and observations. These sections will capture various details, including your patient’s self-report encompassing direct quotes, descriptions of interventions provided, and specifications of equipment used.
Also, key observations, including complications or extreme reactions, periodic patient-reported updates on their status, objective functional measurements illustrating progress toward treatment objectives, and any factors that prompt changes in treatment plans, should be documented in detail. Additionally, the note must be a comprehensive record of communication between you, other healthcare providers, and the patient and their family. This information is then used to offer better care and foster information flow within the medical team.
The fundamental components of a SOAP note include the following:
Header
The header of a SOAP note contains essential patient and session information. It typically includes the patient’s first and last name, date of birth, age, date and time of the session, as well as your name as the physical therapist. This information ensures proper identification and sets the context for the note.
EXAMPLE
Patient: John Doe
Date of Birth: 05/15/1980
Age: 43
Date & Time of Session: 09/08/2023, 10:00 AM
Therapist: Jane Smith, PT
Subjective
In the subjective section, you should record information provided by the patient or primary caregiver. This includes details about the patient’s symptoms, pain level, medical history, and any relevant information from the patient’s perspective. You can use quotes to capture information accurately as conveyed. Also, use this section to document any concerns, preferences, and modifications the patient would like to highlight. This part is essential for understanding the patient’s condition and developing a patient-specific treatment plan.
Typically, this component will record the following information;
- Chief complaint/condition
- Pain scale
- Symptoms experienced
- Factors positively and negatively impacting the symptoms
- Patient’s response to any interventions and home exercise program (HEP)
- Patient’s functional status
- Perceived improvement
- Patient’s level of activity and exercise
EXAMPLE
Patient reports increased pain in the left shoulder (VAS pain scale 6/10) since the last session. States difficulty in lifting objects overhead. No recent changes in medical history.
Objective
The objective section focuses on measurable, objective data gathered during the session. This could consist of a range of motion measurements, muscle strength, joint stability, and other physical assessments. It should be factual and free from interpretation or bias. This information is needed to track changes and make informed decisions throughout the treatment journey.
This section will ordinarily document the following information:
- Range of motion (ROM)
- Manual muscle testing (MMT)
- Posture and biomechanical testing
- Orthopedic special testing
- Reviews of diagnostics performed
- Neurological testing
- Reviews of progress notes
- Vestibular testing
- Women’s health testing
- Vital signs
- Descriptions of interventions implemented, including exercise, modalities, manual therapy, patient education, etc.
EXAMPLE
Range of motion of the left shoulder: Flexion 120 degrees, Extension 30 degrees, Abduction 90 degrees. Muscle strength assessment reveals weakness in the supraspinatus muscle (4/5).
Assessment
In the assessment section, you analyze the subjective and objective data to make a clinical judgment. This may involve diagnosing, identifying impairments and functional limitations, and assessing the patient’s progress or response to previous treatments. You may also use this section to record the modification of objectives, safety concerns, precautions, restrictions, and how the session aligns with the overall goals of the treatment plan. This information is then used to direct the treatment plan.
EXAMPLE
Assessment indicates a rotator cuff injury in the left shoulder, resulting in limited range of motion and muscle weakness. Patient’s pain has slightly increased since the last session.
Plan
The plan section outlines treatment strategies, HEP progression, and interventions proposed to fulfill the patient’s rehabilitation or recovery goals (immediate and long-term). It may also specify patient education, recommendations as well as the frequency and duration of future therapy sessions. Also, it must align with the patient’s condition and unique needs. This component is meant to offer direction to patient care by explicitly clarifying which techniques, exercises, and modalities you intend to use in future sessions.
EXAMPLE
Plan includes a series of therapeutic exercises to improve shoulder strength and range of motion. The patient will continue with heat and ice therapy as needed. Recommend three sessions per week for the next six weeks.
Footer
Lastly, the footer typically includes your signature and the session date. The signature confirms that the SOAP note’s content is accurate and credible. The date is used for record-keeping and tracking of documents. This component also adds a level of professionalism and promotes accountability in the physical therapy industry.
EXAMPLE
Therapist Signature: [Signature]
Date: 09/08/2023
Best Practices for Writing a Physical Therapy SOAP Note
A SOAP note should assist you in providing better physical therapy and overall patient care. Therefore, you must pay attention to every detail you incorporate and how you organize this information.
Below are tips on how to enhance the effectiveness of your note:
Take personal notes
During the session, take personal and detailed notes that capture the patient’s subjective complaints, responses to treatment, observations, and any additional noteworthy information. This will serve as the foundation for your SOAP note and help ensure no important details are overlooked.
Identify treatment goals
Clearly outline specific treatment goals in the plan section of the SOAP note. These therapy goals should be SMART – specific, measurable, achievable, realistic, and directly relevant to the patient’s condition and needs. Setting clear objectives will guide the therapy process and allow for progress assessment.
Use a narrative format
While SOAP notes have a structured format, it is essential to present information in a coherent and logical narrative. This ensures that the note flows naturally and easily guides the reader through the patient’s diagnosis, assessments, and treatment strategies to be used. This information should be presented in a narrative format to produce a note that is easy to follow and offers a comprehensive overview of the patient’s care.
Focus on facts
Focus on objective data, facts, and measurable findings while making assessments. Avoid making subjective interpretations or assumptions. Examples of objective data include vital signs, strength assessments, specific range of motion measurements, etc. Such information enhances the note’s accuracy and reliability.
Maintain clarity and accuracy
Be precise and concise in your documentation. Use clear and straightforward language to describe assessments, interventions, and findings. Avoid ambiguous terms, jargon, or abbreviations that may be unclear to other healthcare providers.
File the notes
After completing your SOAP note, file it in the patient’s medical records. Such documentation is needed to record a patient’s medical history accurately. Also, it makes information contained in the SOAP notes accessible for reference and legal purposes when necessary. Also, ensure that the records are stored in a secure and organized manner.
Frequently Asked Questions
You should complete the SOAP notes during every therapy session. However, you can also do so at regular intervals at your discretion or as guided by the treatment plan. This ensures that the information is up-to-date and supports effective communication and coordination among healthcare providers.
These notes provide a detailed record of a patient’s condition, treatment, and progress, which is valuable for substantiating the medical necessity of services provided. Insurance companies often require such documentation to process claims and determine coverage and reimbursement eligibility for physical therapy treatments.
Yes, SOAP notes are confidential. They contain sensitive patient information and are protected by healthcare privacy laws, such as HIPAA (the Health Insurance Portability and Accountability Act) in the United States. You are thus legally obligated to maintain the confidentiality of these notes. You can only disclose them to authorized individuals involved in the patient’s care or as required by law, such as the patients or their legal guardians.
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