How to take SOAP notes for Physical Therapy (Examples Inside)

Nothing matters more than clear and concise communication in physical therapy; it's the bridge between understanding a patient's needs and designing an effective treatment plan. 

And that’s why we can’t understate the importance of SOAP notes (and no, they have nothing to do with personal hygiene products). It’s the structured documentation system that serves as the backbone of efficient care.

So, if you’re just getting into this profession, finding a reliable physical therapy SOAP note example is essential.

In fact, clinicians typically spend 4.5 hours per day taking notes and entering them into electronic health records (EHRs) - So you’ll want to start off on the right foot.

In this article, we’ll cover:

SOAP is not about cleanliness, but it is about neatness

SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter represents its own segment within the note, painting a holistic picture of a patient's encounter with a physical therapist.

Beyond recording information, SOAP notes serve other important purposes:

How to write SOAP notes: A step-by-step guide

Now that we've unraveled the acronym, it's time to get into the practicalities of writing SOAP notes. 

Each section will have part of a physical therapy SOAP note example to help you ease your way into the process.

Let’s take a look below: 

Subjective (S): Or, the patient’s voice

This section is all about getting the patient’s perspective down.



Objective (O): This is when you come in

This section documents your keen observations and findings through physical examination and standardized tests.

Following the previous physical therapy SOAP note example:



Try to use accurate and specific medical terms to describe your findings. Draw on experience. Also, quantify measurements whenever possible, like range of motion and muscle strength.

Then, thoroughly document any abnormalities or deviations from normal values.

Assessment (A): Time to connect the dots

This section brings together the subjective and objective findings to form a diagnosis and treatment plan.

Here’s the appropriate physical therapy SOAP note example: 



Try to explain the reasoning for your diagnosis and treatment plan clearly, making sure to discuss any possible uncertainties. 

Don’t just go it alone, though! Involve the patient in the decision-making process and address their questions and concerns.

Plan (P): Chart a course

Now, it’s time to crack your knuckles and actually give the patient-specific interventions and recommendations.

In this specific physical therapy SOAP note example, they are: 

Physical therapy SOAP note example #1: Chronic low back pain

Let’s take a look at what the SOAP note may look like for Jane Smith, a poor soul who cracked her back while she was lifting a box when moving to a new house. 

Here’s what it looks like: 

Patient: Jane Smith, 45-year-old female.

Chief complaint: "Dull aching pain in my lower back that worsens with sitting for extended periods and bending over. It makes it hard to work at my desk and enjoy playing with my kids."

History of present illness: Onset 6 months ago after lifting a heavy box. Pain is constant, but intensity varies.

Past medical history: No surgeries or major medical conditions.

Functional limitations: Difficulty sitting for longer than 30 minutes, trouble bending down to pick up objects, decreased activity level due to pain.

Goals and expectations: Wants to reduce pain, improve flexibility and strength in her back, and return to regular activities without limitations.

Subjective findings: Positive for lumbar spinal tenderness on palpation, reports decreased flexibility in bending forward. Denies radiating pain, numbness, or tingling.

Objective findings: Range of motion in lumbar spine restricted, slight antalgic gait observed during walking. Lumbar lordosis flattened. Myofascial trigger points identified in paraspinal musculature.

Assessment: Chronic lumbar strain with secondary myofascial trigger points contributing to pain and stiffness.


Physical therapy SOAP note example #2: Rotator cuff tendinitis

Now, it’s time for John Smith’s turn. John has bad inflammation on his rotator cuff due to going too hard on the tennis court. It seems this family can’t catch a break!

Let’s take a look at this second physical therapy SOAP note example:

Patient: John Smith, 50-year-old male.

Chief complaint: "Sharp pain in my right shoulder when reaching overhead or behind my back, especially noticeable when throwing a ball or playing tennis."

History of present illness: Gradual onset over the past few months. Pain initially mild, worsening with activity.

Past medical history: No major medical conditions, history of occasional shoulder pain in the past.

Functional limitations: Difficulty reaching overhead to put on clothes, limitations in throwing and playing overhead sports.

Goals and expectations: Wants to reduce pain, regain full range of motion and strength in his shoulder, return to playing tennis without limitations.

Subjective findings: Positive for pain on resisted abduction and external rotation of the right shoulder. Reports weakness and reduced range of motion compared to the left shoulder.

Objective findings: Restricted range of motion in abduction and external rotation of the right shoulder. Palpation reveals tenderness over the greater tuberosity. Positive Neer impingement and Hawkins-Kennedy tests.

Assessment: Rotator cuff tendinitis, likely involving the supraspinatus muscle.


How to conquer the SOAP note time crunch with AI

Time matters, especially time with your patients. And the best way to get reliable and well-written SOAP is by using an AI tool.

But not all tools are created equal, and that’s why we’ve got a treat for you: Lindy, a cutting-edge AI assistant that will help you save time and take your notes to the next level. 

Lindy will help you by providing: 

Using Lindy isn't just about saving time, it's about enhancing your practice:

While Lindy won’t replace your clinical expertise, it can be a powerful ally for optimizing your workflow and allowing you to save up to 2 hours every day.

 Then, you can focus on what you do best: providing your patients with the best possible care.

Summing up

SOAP notes are more than just paperwork or a chore; they’re a way to translate patient needs into a plan that will–hopefully–help them regain their health or manage any ongoing conditions.

In their well-defined sections, they tell a story: challenges, progress, setbacks, and the roadmap to recovery. 

So, take the time to master the art of SOAP note-writing. Study each physical therapy SOAP note example, internalize the structure, and get cracking!