Physical Therapy SOAP Note

Current Condition/Complaint:

• [Symptom status since last visit] (Describe changes in pain or function compared to prior session; only include if explicitly mentioned)

• [New symptoms or concerns] (State if any new issues have emerged or deny if none; only include if explicitly mentioned)

• [Adherence to home program or self-management strategies] (Include frequency/consistency; only include if explicitly mentioned)

• [Use of medications or adjuncts for symptom management] (Name, dose/frequency if provided; only include if explicitly mentioned)

• [Relevant diagnostics or test results reviewed] (Summarize key findings and clinical relevance; only include if explicitly mentioned)

Objective:

• Active Range of Motion (AROM):

  • [Region/movement and measurement] (List each tested movement with values and units; include side if applicable; repeat as needed)

• Strength Testing:

  • [Muscle group and side with grade/scale] (Document using standard grading; repeat as needed)

• Palpation:

  • [Findings and locations] (Note tenderness, tone, trigger points, tissue quality; specify structures/regions)

Treatment:

• Educational Treatment:

  • [Psychoeducation and self-management topics covered] (Include rationale, posture/body mechanics, activity modification, pacing, or symptom management; only include if explicitly mentioned)

• Hands-On Treatment:

  • [Manual therapy techniques performed] (Specify technique/type, target region/segment, side, parameters such as grade, duration, sets; only include if explicitly mentioned)

  • [Soft tissue or other hands-on techniques] (Specify location, technique, and dosage; only include if explicitly mentioned)

• Active Therapy Treatment:

  • [Therapeutic exercises/activities] (List exercise name with side if applicable and include sets, reps, resistance, tempo, and rest; repeat as needed; only include if explicitly mentioned)

• Home Exercise Program (HEP):

  • [Exercises prescribed or progressed] (Include name, frequency, sets/reps/hold times, and any precautions or cues; only include if explicitly mentioned)

Assessment:

• [Clinical response and progress] (Summarize changes in pain, mobility, strength, and function; only include if explicitly mentioned)

• [Working diagnosis or primary impairment(s)] (State if unchanged or updated based on current findings; only include if explicitly mentioned)

• [Progress toward goals and anticipated outcomes] (Reference functional goals and expected timeline; only include if explicitly mentioned)

• [Barriers or facilitators to progress] (Note any limiting factors or none if not present; only include if explicitly mentioned)

Plan:

• [Planned modifications to treatment/HEP] (Continue, progress, or add specific components; include rationale; only include if explicitly mentioned)

• [Follow-up timing] (Specify interval for next visit; only include if explicitly mentioned)

• [Focus for next session] (Outline anticipated progression of interventions such as strengthening, motor control, manual therapy, or neuromuscular training; only include if explicitly mentioned)

• [Referrals or consultations] (Indicate need for referral or none if not indicated)

• [Care coordination/communication] (Identify communications to other providers or updates to stakeholders; only include if explicitly mentioned)