Physical Therapy Daily Treatment Note (SOAP)

Date of Service: [date] (Always include)

Treating Clinician: [name, credentials (PT or PTA), and role] (Always include)

Location: [care setting or telehealth platform] (Omit if not documented)

Encounter Type: [in-person / telehealth]; [individual / group]

Precautions: [active weight-bearing restrictions, ROM limits, cardiac precautions, fall risk, or other safety considerations] (Omit this line entirely if none apply)

Subjective

[Patient-reported status since last visit] (2–5 sentences using "patient reports" or "caregiver reports" phrasing. Include pain rating with context, functional changes, HEP adherence, and any red flags or new symptoms. If patient cannot provide input, state the reason and alternative source. Do not infer symptom changes.)

Objective

Measures: [relevant objective findings: ROM, strength, gait speed, balance time, vital signs, functional performance as applicable] (Omit this line if no formal measures were performed)

Interventions: (Document each skilled intervention using CPT-aligned terminology. For each, include: intervention category, brief description of skilled activity, parameters as applicable, assistance/cueing level, and patient response. Emphasize what required clinical skill.)

• [CPT-aligned intervention category]: [skilled activity description]; [parameters: sets/reps, resistance, distance, duration as applicable]; [assistance/cueing level]; [patient response and tolerance] (Repeat for each distinct billed intervention)

Education/HEP: [topics addressed, patient understanding, home program updates with dosage/frequency] (Omit if none provided or changed)

Assessment

[Clinical interpretation of today's session] (3–6 sentences. Describe patient's response to treatment with specific symptom and performance changes. Reference progress toward established goals. Explain why PT skill was required—cueing, manual techniques, safety management, progression decisions. If plateauing or regressing, document suspected cause and planned response.)

Plan

• [Planned focus and progressions for next visit]
• [Reassessments to perform] (Omit if none planned)
• [Coordination/communication needs] (Omit if none)
• [Discharge planning cues] (Include when approaching goals or discharge)
• [Changes to frequency, duration, or approach with brief justification] (Include only if changed from plan of care)

Time and Billing Summary

• [CPT code] [description]: [X] min → [Y] unit(s) (Repeat for each timed code; include PT/PTA breakdown only if both furnished timed services)
• Total timed minutes: [X]
• Untimed services: [list codes/descriptions] (Omit if none)
• Total treatment time: [X] min

Signature: [author signature with credentials and license number per organizational policy] (Do not include co-signatures unless supervisor actively participated and policy requires it)

Contributors: [names and roles of additional personnel] (Omit if single provider)