Athletic Therapy Treatment/Progress Note (SOAP)

Visit Information

Patient: [name]
DOB/ID: [DOB or MRN/athlete ID]
Date of Service: [date]
Visit #: [visit number or post-op week/RTP stage]
Condition: [body region + laterality + working diagnosis]
Precautions: [current restrictions, weight-bearing status, protocol limits, or "None"]
Clinician: [name, credentials]

Subjective

(Summarize patient-reported status since last visit in a brief narrative or concise bullets. If no changes, explicitly state "unchanged from last visit." Use "not reported" for information not obtained rather than leaving blank.)

[Current symptoms with pain rating/scale, location, quality; functional tolerance and activity limitations; HEP adherence and response; interim events such as re-injury, practice/game exposure, or physician visits]

(Include a direct patient quote only if it materially affects clinical decisions.)

Objective

(Document clinician-observed or measured findings. If a commonly expected measure was not assessed, document "Not assessed today: [rationale]" rather than leaving blank.)

Observations: [relevant findings: swelling, gait, movement quality, device use]

Key Measures: [at least one objective anchor per visit—ROM, strength, functional test, or PROM score with comparison to prior values when repeated] (If none measured, state rationale.)

Interventions: [techniques and exercises performed with parameters—sets/reps/load, duration, settings as applicable; note progressions or regressions from last visit; document patient tolerance] (Do not enumerate every intervention type; include only what was actually performed.)

Assessment

[Clinical interpretation of today's session linking objective findings to functional progress or persistent limitations; treatment tolerance; reasoning for any progression or regression decisions; barriers or concerns if present] (If this visit is a progress-report interval, include explicit goal status: [on track / ahead / behind] with supporting evidence.)

Plan

Next Visit Focus: [planned progressions or treatment emphasis]
HEP: [updates with dosage and stop rules, or "unchanged"]
Restrictions/RTP Status: [current participation guidance; RTP stage; criteria to advance]
Communication: [updates to physician, coach, or other stakeholders if applicable]
Referral/Escalation: [planned consult or imaging discussion if indicated]

Clinician Signature: [signature, credentials, date/time]

(Do not infer symptoms, adherence, or measurements not directly obtained. Clinical reasoning in Assessment may draw inferences only when tied to documented Subjective and Objective findings.)