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]