Sports Medicine SOAP Note

Date: [Date]

Visit Type: [new / established]; [in-person / telehealth]

Referral Source: [Referring clinician or service] (Omit if none)

Administrative Context: [worker's compensation / athletic clearance / pre-participation / second opinion / other] (Omit if none)

Subjective

Chief Complaint: [Primary reason for visit]

History of Present Illness: [Narrative covering onset and chronology; mechanism of injury (contact vs non-contact, twisting, overuse, etc.); symptom characteristics (location, quality, swelling timing, instability, locking, weakness, neurovascular symptoms); functional impact (weight-bearing, ability to continue play, sport-specific limitations, ADLs); aggravating/alleviating factors; prior episodes and treatments tried. Include sport/activity context relevant to management: sport, position, level, training load changes, equipment factors, upcoming competitions, athlete goals. Include red-flag symptoms only when clinically indicated.] (Synthesize into 1–2 concise paragraphs. Use brief direct quotes only for goals or constraints influencing shared decision-making.)

Relevant History: (Omit this section entirely if nothing relevant.)

• [Pertinent past medical and surgical history]
• [Current medications and supplements relevant to condition or treatment safety]
• [Allergies relevant to planned treatment]
• [Prior relevant imaging with study type and date]

Objective

General: [Appearance; gait pattern; gross alignment or deformity] (For telehealth, note examination limitations.)

MSK Exam: (Document only maneuvers performed. Compare to contralateral side when useful. If exam limited by pain or guarding, state explicitly.)

• Inspection: [Swelling; ecchymosis; atrophy; scars; alignment]
• Palpation: [Tender structures by anatomic landmark; crepitus; warmth]
• Range of Motion: [Active/passive ROM; quantify when meaningful] (Note if pain-limited vs fixed restriction.)
• Strength: [Key muscle groups with grades] (Indicate if pain-limited.)
• Neurovascular: [Sensation; reflexes; pulses] (Include only if assessed.)
• Stability/Special Tests: [Tests performed with positive/negative findings; include grading when standard]
• Functional Testing: [Gait; squat; hop; sport-specific tasks] (Include only if performed.)

Diagnostics: [Studies reviewed with date, source, and key findings; distinguish radiology report review from independent clinician interpretation] (Omit this section entirely if no studies were reviewed.)

Assessment

1. [Problem 1]: [Working diagnosis or symptom-based assessment; acuity; key supporting findings; differential diagnosis with risk framing when uncertainty remains; contributing factors such as training errors, biomechanics, or equipment] (Include elements only as applicable.)
2. [Problem 2]: [As above] (Add additional problems as needed.)

Plan

(Organize by problem, matching the Assessment numbering.)

1. [Problem 1]:
   • Diagnostics: [Imaging or lab orders with rationale; referrals/consults]
   • Treatment: [Rehab plan and PT prescription (frequency, duration, focus); home exercise program; medications with dose/duration; injections or procedures; bracing/DME] (If procedure performed, reference separate procedure note.)
   • Activity/Return-to-Sport: [no restriction / modified / not cleared]; [Specific restrictions and allowed alternatives]; [Criteria-based progression and clearance criteria] (Document shared decision-making when timing is event-driven.)
   • Education: [Diagnosis explanation; expected course; red flags to monitor; prevention]
   • Follow-up: [Interval; return-sooner triggers; planned reassessments]
   • Work/School/Athletic Documentation: [Restrictions or clearance forms] (Include only when applicable.)
2. [Problem 2]: [Plan as above]

(If relevant information is unknown, document as "Unknown" or "Not obtained." Omit sections or bullets not applicable to this encounter.)