PM&R Outpatient Progress Note (SOAP)

Date: [date of service]

Patient: [name, DOB, MRN]

Provider: [rendering clinician]

Visit Type: [in-person / telehealth]

Chief Concern: [brief reason for visit]

(If elements in the sections below are not documented, omit them rather than inserting placeholders. Retain bracketed placeholders above for Date, Patient, and Provider if missing.)

Subjective

[Interval history since last PM&R visit] (Summarize what has improved, worsened, or remained stable, including any new symptoms, falls, hospitalizations, or imaging since the prior encounter.)

[Current status of each major problem and functional impact] (Include pain severity with modifiers and functional consequences: mobility tolerance, ADL limitations, work or school capacity, sleep disruption, and the patient's stated goals.)

[Prior and current conservative treatments with responses] (Specify therapies performed with duration and response; medications trialed with effectiveness and side effects; injections or procedures attempted with duration of benefit. Note current therapy attendance, DME or brace use and tolerance, and any adherence barriers. For controlled substances, document functional benefit and safety concerns.)

[Red-flag symptoms if relevant] (Document presence or absence of progressive weakness, bowel or bladder changes, saddle anesthesia, fever, or unexplained weight loss only when pertinent to decision-making.)

Objective

Vitals: [BP, HR, weight as relevant]

Exam: [pertinent MSK and neurologic findings by region or system assessed; include gait pattern, device use, and standardized functional test scores with direction of change when performed] (Document only findings that influence diagnosis or plan. Note device fit and skin integrity if applicable.)

Data Reviewed: [pertinent imaging, EMG/NCS, labs, or outside records with date, source, and key findings correlated to symptoms] (Include only studies reviewed that inform today's assessment.)

Assessment

[One-sentence clinical summary integrating key diagnoses with their functional consequences and the visit purpose]

[Problem 1]: [Diagnosis with laterality or level]

[Primary functional limitation]. [improving / stable / worsening] since last visit. (If diagnosis is uncertain, state differential and what will clarify it. Note contributing factors—deconditioning, fear avoidance, mood, cognition, social barriers—when they affect the plan.)

[Problem 2]: [Diagnosis]

(Include additional problems only if addressed today; follow the same structure.)

Plan

Problem 1

Goals: [short-term and long-term functional goals with timeframes] (Make goals specific and measurable.)

Interventions: [therapy referrals with target impairments and frequency; medication changes with dose and rationale; planned procedures with indication; DME orders with medical necessity; diagnostics ordered or deferred with reasoning; referrals with clinical question; work or activity restrictions with re-evaluation timeframe] (Include only interventions relevant to this problem.)

Safety and Follow-up: [red flags and return precautions; follow-up timing and modality; what will be reassessed]

Problem 2

(Include only if Problem 2 is listed above. Mirror the structure for Goals, Interventions, and Safety/Follow-up.)