Physical Therapy SOAP Note Template

A physical therapy SOAP note records a treatment visit: what the patient reports, what you measured, the skilled care you gave, and what comes next. Copy the free template, see two filled examples, and check what each section needs.

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Blank physical therapy SOAP note template

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PHYSICAL THERAPY SOAP NOTE

Patient: [Name]
Date of birth: [Date]
Date of visit: [Date]
Visit: [Visit number, and total visits in the plan of care]
Treatment diagnosis: [Condition, body region, and side]
Precautions: [Surgical protocol, weight-bearing status, medical precautions, or none]
Therapist: [Name, credentials]

SUBJECTIVE
Since last visit: [Change in symptoms and function, and response to the last session]
Pain: [Rating out of 10 now, at best, and at worst; location; what eases or aggravates it]
Function: [Activities the patient reports are easier or still limited]
Home exercise program: [How often it was done, and any difficulty]
Screening: [New symptoms, falls, medication changes, and red flags asked about]

OBJECTIVE
Observation: [Posture, swelling or effusion, incision or skin, assistive device]
Range of motion: [Joint and motion, active or passive, degrees, side]
Strength: [Muscle group, manual muscle test grade out of 5 or dynamometry, side]
Special tests: [Test, result, side]
Gait and balance: [Device, gait pattern, distance, balance test and result]
Functional measure: [Outcome measure or performance test and score, with the previous score]
Interventions: [Each skilled intervention with key parameters and minutes]
Response to treatment: [Change in pain, motion, or function within the session, and tolerance]
Total treatment time: [Minutes]

ASSESSMENT
Progress: [Better, unchanged, or worse since the last visit, and the findings that show it]
Impairments: [Remaining impairments and the activities they limit]
Skilled need: [Why today's care required a physical therapist]
Goal status: [Each goal: met, progressing, or not yet met]

PLAN
Next visit: [What to progress, add, or re-test]
Frequency and duration: [Visits per week, and weeks remaining]
Home exercise program: [Changes made today, with sets, reps, and how often]
Education and coordination: [Advice given, and contact with the referring clinician or surgeon]

Signed: [Clinician name, credentials, date and time]

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Use it for

Outpatient follow-ups
Post-surgical rehab
Sports injuries
Spine and chronic pain
Home health visits

Two filled examples. Every part, filled in.

Each one follows the template. Use them to judge how much detail every part needs.

Physical therapy SOAP note: 6 weeks after ACL reconstruction

Outpatient orthopedic clinic, visit 11

Subjective

24-year-old woman, 6 weeks after a right ACL reconstruction with a hamstring autograft. Walking without crutches for 2 weeks. Knee stiff for about 10 minutes each morning. Pain 2/10 at rest, 4/10 after standing for an hour at work, with a little more swelling at the end of a long shift. Climbs stairs step-over-step going up; going down, still takes one step at a time, right leg first. Home program once a day, most days. No giving way, calf pain or swelling, or fever.

Objective

Incision healed. Trace effusion on the stroke test. Knee AROM right 0 to 118°, was 105° two weeks ago; left 0 to 140°. Superior patellar glide slightly reduced. Quadriceps 4-/5 right, 5/5 left; no extensor lag on straight-leg raise. Hip abductors 4/5 right. Walks without a device, with slightly reduced right knee flexion in swing. Single-leg stance 20 s right, 30 s left. LEFS 52/80, was 31/80 at the evaluation. Interventions: stationary bike 10 min; quadriceps NMES with isometric knee extension at 60°, 10 contractions at maximum tolerated intensity, 12 min; double-leg press 3 × 12 at 40 kg (88 lb), step-ups on a 15 cm (6 in) step 3 × 10, and single-leg balance on foam 4 × 30 s, 20 min; patellar and knee flexion mobilizations, grade III, 8 min. Flexion 122° after the bike and mobilizations. No increase in pain or effusion by the end. Total treatment time 50 min.

Assessment

Progressing as expected at 6 weeks. Full extension and improving flexion. Quadriceps weakness and reduced single-leg control are now the main limits on stairs and long shifts on her feet. Needs skilled progression of loading within the surgeon’s graft protection timeline, guided by the effusion response. Goals: full knee extension, met; flexion 120° or more, progressing; reciprocal stairs, progressing.

Plan

Twice a week for 6 more weeks, then re-assess. Next visit: add forward step-downs if the effusion stays trace or less. Start resisted knee flexion at week 8, per the surgeon’s protocol. Home program: added wall sits 3 × 30 s and single-leg balance 3 × 30 s, daily; she showed both correctly. Ice and elevation after long shifts. Call the clinic or surgeon for a sudden increase in swelling, giving way, calf pain or swelling, or fever.

Physical therapy SOAP note: chronic low back pain

Outpatient clinic, visit 5

Subjective

52-year-old bus driver with low back pain for 8 months, central and across both sides, without leg symptoms. Pain 4/10 today, ranging from 3 to 6/10 this week. Worse after sitting for more than 45 minutes on a route; eases with walking. Walked 20 minutes on 4 days, up from 10 minutes. Home program 5 days a week. Still worried that bending will “damage” his back. Denies saddle numbness, bladder or bowel changes, leg weakness, fever, and weight loss.

Objective

Lumbar flexion to mid-shin, with guarding on the return to upright. Extension full, mild pain at end range. Straight-leg raise and slump test negative on both sides; lower limb strength, sensation, and reflexes normal. Hip extensors 4/5 on both sides. Side plank 20 s right, 18 s left. Five Times Sit to Stand 11 s. Oswestry Disability Index 30%, was 42% at the evaluation. Interventions: pain education on sensitivity and safe movement, 10 min; lumbar central posteroanterior mobilization, grade III, 8 min; hip hinge with a dowel 3 × 10, bridges 3 × 12, bird dog 3 × 10 each side, and carrying 8 kg (18 lb) for 4 × 20 m (65 ft), 27 min. Lifted a 5 kg (11 lb) box from a low shelf with good form and less guarding by the end. Pain 3/10 after the session. Total treatment time 45 min.

Assessment

Chronic low back pain without neurological signs, improving. Oswestry down 12 points since the evaluation and walking tolerance doubled. Fear of bending and low trunk and hip endurance still limit lifting and long periods of sitting at work. Skilled care needed to progress graded loading and to address fear-avoidance beliefs. Goal: sit for 60 minutes with pain 3/10 or less, progressing.

Plan

Once a week for 4 weeks, then re-assess with the Oswestry. Next visit: progress lifting from floor height and add a simulated task from his work. Home program: hip hinge with a light load 2 × 10 daily; build walking to 30 minutes; stand and walk for a few minutes at every layover. Reviewed warning signs: saddle numbness, new bladder or bowel problems, or worsening leg weakness need same-day medical review.

What goes in each part.

Subjective

What the patient tells you about the time since the last visit: symptoms, function, and how the home program went.

Pain out of 10 now, at best, and at worst
Activities that are easier or still limited, in the patient’s words
How often the home program was done, and any trouble with it
New symptoms, falls, or medication changes, and the red flags you asked about

Avoid: “Patient doing well” on its own. Name the activity that changed, such as stairs, sleep, or lifting.

Objective

What you measured and what you did, in numbers another therapist could repeat at the next visit.

Range of motion in degrees, active or passive, with the side
Manual muscle test grades or dynamometry
Special tests by name, with the result
Gait, balance, or a functional measure, with the previous score
Each intervention with its parameters and minutes, and the response

Avoid: “ROM improved” without degrees, or a measure with no side. The numbers are what show change.

Assessment

Your interpretation: whether the patient is progressing, what still limits function, and why skilled care is still needed.

Progress since the last visit, tied to a measure
Impairments linked to the activities they limit
Why today’s session needed a physical therapist
The status of each goal

Avoid: Repeating the objective findings. Say what they mean for the patient’s goals.

Plan

What happens next: the next visit, what is left of the plan of care, and the home program.

What you will progress, add, or re-test next time
Visits per week and weeks remaining
Home program changes, with sets, reps, and frequency
Contact with the referring clinician or surgeon

Avoid: “Continue per plan of care” and nothing else. Name the next progression.

Common mistakes, and how to avoid them.

Leaving out the minutes

Record minutes for each intervention and the total treatment time. Without them, the note can’t show what the visit involved, and many payers ask for them.

A list of exercises, not skilled care

Sets and reps alone read like a gym log. Say what you assessed, progressed, cued, or changed, and why it needed a therapist.

Measures with no side or baseline

Record the side, whether it was active or passive, and the last value or the other side. “Flexion 118°” means more next to “105° two weeks ago.”

Goals missing from the visit

Each visit should show where the patient stands on the plan of care goals, even in one line.

Home program changes not recorded

If you changed the home program, record what changed, the dose, and that the patient showed it back to you.

Related formats, and when they fit better.

Physical therapy daily note

A shorter session log that puts each intervention’s parameters and minutes first. Common for visits between fuller SOAP notes.

Learn more

Physical therapy progress report

A periodic re-assessment that sets today’s measures beside the baseline and updates the goals.

Learn more

Physical therapy evaluation

The first visit: history, tests and measures, prognosis, goals, and the plan of care.

Learn more

SOAP note

The general four-part note that this version adapts for physical therapy.

Learn more

Let Vero fill it in from the session.

Vero Scribe writes the physical therapy SOAP note in your template from the session conversation, with the patient’s consent, or from your dictation. You review and edit it, then copy it into your EMR.

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Frequently asked questions.

What should a physical therapy SOAP note include?

The patient’s report and pain rating; objective measures such as range of motion, strength, special tests, and a functional measure; the skilled interventions with minutes and the response; your assessment of progress toward goals; and the plan, with the home exercise program.

Where do interventions go in a PT SOAP note?

Most therapists record them in Objective, with parameters, minutes, and the patient’s response. Some clinics add a separate Treatment section. Either works if each intervention, its dose, and its time are clear.

How do you show skilled care in a physical therapy note?

Describe your clinical decisions: what you assessed, how and why you progressed or modified the exercise, the cues or hands-on care needed, and the response. A list of exercises with sets and reps doesn’t show it on its own.

Can physiotherapists use this template?

Yes. Physical therapy and physiotherapy notes record the same things. Adjust the headings and abbreviations to your clinic and your regulator’s record-keeping standards.

Is this physical therapy SOAP note template free?

Yes. Copy it, or download it as a Word or text file. No account needed.

Can Vero write my PT SOAP notes?

Yes. Vero Scribe writes the note in your template from the session conversation, with the patient’s consent, or from your dictation. You review and edit it before it goes into your EMR.