How to Write SOAP Notes for Physical Therapy? (With Examples)

A physical therapy SOAP note is a structured clinical document used to record patient encounters in physiotherapy settings. It stands for Subjective, Objective, Assessment, and Plan, four sections that help providers organize relevant clinical information during evaluations, follow-ups, or treatment sessions.

Unlike general medical notes that may focus on diagnostics or lab values, a PT SOAP note focuses on pain, mobility, function, strength, and rehabilitation progress. It documents what the patient says, what the therapist observes and measures, how the condition is interpreted, and what the next steps in treatment will be.

SOAP notes in physical therapy are used to:

• Track functional progress over time
• Justify skilled intervention for insurance reimbursement
• Create a legal record of care and decision-making
• Communicate clearly across multidisciplinary teams

A well-written PT SOAP note ensures continuity of care and protects both the therapist and patient by thoroughly documenting clinical findings and interventions. Whether you’re working in outpatient rehab, post-op recovery, or neurological physiotherapy, SOAP is the standard format across most PT documentation workflows.

How to Write a Physical Therapy SOAP Note: Step-by-Step Example

Here’s how to write a physiotherapy SOAP note for a real-world outpatient case, broken down section by section.

Patient Profile

Note: The following patient profile is entirely fictional and created for educational purposes only. It is not based on any real individual or identifiable patient record.

• Name: Aaron M.
• Age: 36
• Gender: Male
• Setting: Outpatient orthopedic physiotherapy (Visit #3)
• Diagnosis: Right patellofemoral pain syndrome
• Referral: From an orthopedic physician after persistent anterior knee pain for 3+ months
• History: No history of trauma; pain began gradually while training for a 10 K. Worsens with running, stairs, and prolonged sitting.
• Occupation: Software engineer, works at a desk 8–10 hours daily.
• Activity Level: Recreational runner
• Goals: Return to pain-free running and functional stair climbing
• Medical History: Non-contributory
• Medication: Occasional NSAIDs PRN
• Support System: Lives with spouse, supportive home environment
• Imaging: X-ray unremarkable

Subjective (S)

Aaron reports that anterior knee pain has slightly decreased since starting therapy, but is still limiting daily activity.

“It’s better than last week, but I still can’t jog without feeling that dull pressure under my kneecap. Sitting for more than 20 minutes makes it throb a little.”

Rate pain at 3/10 at rest, 5/10 after activity. Denies swelling, locking, or instability. Reports compliance with home exercises 4x/week. States goal of resuming short runs within a month.

What This Means:

This physical therapy SOAP note example captures patient-reported symptoms, activity tolerance, adherence to home exercise, and functional goals. Specific quotes and functional descriptions guide the objective evaluation and future treatment planning.

Objective (O)

Observation: Mild genu valgum bilaterally. No effusion or discoloration at the knee.

ROM:

• Knee flexion: 135° (full)
• Knee extension: 0°

Strength Testing (Right Lower Extremity):

• Quadriceps: 4-/5
• Hip abductors: 4/5

Special Tests:

• Patellar grind test: Positive with discomfort
• Step-down test (8-inch): Pain reproduced on the right side

Gait: Slight valgus collapse noted on the right during single-leg stance

What This Means:

The objective section documents observable deficits in strength, function, and biomechanics. Positive orthopedic tests and functional assessments (like the step-down test) support the diagnosis and justify the treatment plan.

Assessment (A)

Aaron continues to show signs consistent with right patellofemoral pain syndrome, with contributing factors including quadriceps weakness, dynamic valgus, and poor neuromuscular control during single-leg activities.

Improved tolerance with basic activity, but still unable to jog or climb stairs without pain.

Demonstrates motivation and good compliance with therapy. No red flag findings or need for referral at this time.

What This Means:

This section ties together the subjective complaints and objective findings into a meaningful clinical interpretation. It confirms progress, identifies barriers to recovery, and rules out concerns requiring outside intervention.

Plan (P)

Note: Exercise and rehab protocols listed here are for illustrative purposes only.

• Continue: Supine quad sets, straight-leg raises, glute bridges.
• Progression:
  
  • Add closed-chain exercises: wall sits, mini-squats
  • Begin step-down training from a lower height.
  • Introduce resistance band hip abduction.
    
    
• Education: Postural correction during sitting, ergonomic desk setup
• Home Program: Increase frequency to daily (with low reps)
• Monitoring: Reassess strength and step-down pain in 1 week
• Visits: Continue 2x/week for 3 more weeks, then reassess for running prep

What This Means:

A strong PT SOAP note ends with a clear, actionable plan showing treatment progression, patient, and a follow-up schedule. This ensures clinical accountability and continuity of care.

10 Real-World Physical Therapy SOAP Note Examples

Each of these examples shows how a physical therapy SOAP note might look in real-world outpatient rehab practice. The cases are fictional but realistic, useful for clinicians, students, and anyone learning how to document physiotherapy sessions using the SOAP format.

1. Example SOAP Note For ACL Reconstruction Rehab

S:

Patient reports mild swelling after extended walking. “I can go upstairs without holding the railing now, but I still feel tightness when bending past 90 degrees.” No pain at rest. Denies instability or giving way.

O:

ROM: Knee flexion 110°, extension 0°.

Strength: Quadriceps 4/5, Hamstrings 4/5 (right).

No joint effusion observed. Ambulating independently with a normal gait pattern. No assistive device required.

A:

Post-op week 4 status is consistent with expected recovery milestones. Knee ROM improving. Quadriceps strength is improving, but still needs targeted activation. Patient is motivated and compliant with HEP (Home Exercise Program).

P:

Continue quad strengthening and proprioception drills. Introduce mini squats and step-downs. Encourage stationary cycling for mobility. Schedule a follow-up in 3 days.

2. Example SOAP Note For Lower Back Pain

Here’s a SOAP note example for lower back pain or acute mechanical low back pain

S:

Patient reports 6/10 low back pain after lifting a heavy object at work two days ago. “It feels tight and sore when I bend forward or sit for too long.” No radiating symptoms. No history of previous episodes.

O:

ROM: Lumbar flexion limited to 40°, extension 20°.

Palpation: Tenderness at L4-L5, increased tone in paraspinals.

Negative straight leg raise bilaterally. No sensory deficits noted. Gait was slightly guarded.

A:

Findings suggest acute lumbar strain. No signs of nerve root involvement. The patient demonstrates flexion-biased movement restriction.

P:

Begin lumbar stabilization program with supine pelvic tilts and abdominal bracing. Apply moist heat. Educate on posture and lifting mechanics. Reassess in 1 week.

3. Example SOAP Note For Shoulder Pain 

Here’s a SOAP note example for shoulder pain or Rotator Cuff Tendinopathy (Chronic Overuse)

S:

Patients complain of right shoulder pain with overhead activities, especially reaching and lifting. “It aches by the end of the workday, and I feel weak raising my arm above my head.” Pain level 4/10.

O:

ROM: Shoulder abduction 140°, external rotation 70°.

Strength: Supraspinatus 4-/5 with pain on resistance.

Positive Hawkins-Kennedy and Neer impingement signs. No visible atrophy. Scapular dyskinesis noted.

A:

Signs consistent with rotator cuff tendinopathy. Functional limitations during overhead reaching. Needs scapular stabilization and eccentric strengthening.

P:

Initiate rotator cuff eccentric program. Include scapular retraction and wall slides. Educate on workspace ergonomics. Reassess in 10 days.

4. Example SOAP Note For Hip Replacement

S:

Patients report “steady improvement” in walking endurance and balance. Mild soreness after longer walks. “I feel stronger overall, but the stairs are still tiring.” No pain at rest. Using a cane occasionally outdoors.

O:

ROM: Hip flexion 100°, extension 10°, internal rotation 15°.

Strength: Hip abductors 4/5, extensors 4-/5 (right).

No signs of joint instability. Gait is mildly antalgic. No Trendelenburg sign observed.

A:

The patient shows typical post-op recovery at 6 weeks. Strength improving. Still limited in higher-demand tasks. Needs endurance and stair tolerance focus.

P:

Progress to resistance band glute medius strengthening. Begin stair training with step-ups. Encourage daily 20-minute walks. Discontinue cane as tolerated. Next follow-up in 1 week.

5. Example SOAP Note For Cervical Radiculopathy – Initial Evaluation

S:

Patient complains of neck pain with radiating tingling into the left arm. “It’s worse when I look down or turn my head left. Sometimes my fingers go numb.” Pain is rated 5/10, worsens with sitting at a desk.

O:

ROM: Cervical rotation left limited to 45°, flexion to 60°.

Positive Spurling’s test on the left. Decreased sensation in the C6 dermatome. Strength: Biceps 4/5 (left). Forward head posture noted.

A:

Symptoms and signs consistent with left-sided cervical radiculopathy, possibly C5-C6 involvement. Positional symptoms suggest a mechanical component.

P:

Start cervical traction (light manual). Introduce nerve gliding exercises. Ergonomic education. Monitor for neurological progression. Follow-up in 3 days.

6. Example SOAP Note For Ankle Pain / Injury

S:

The patient twisted their right ankle while running 4 days ago. “It’s swollen and hurts to put full weight on it.” Pain is 6/10 while walking. Denies numbness or tingling. Using crutches as needed.

O:

Swelling over the lateral malleolus.

ROM: Dorsiflexion 5°, Plantarflexion 25° (limited by pain).

Positive anterior drawer test. Bruising present. Gait: partial weight-bearing with antalgic pattern.

A:

Grade II lateral ankle sprain. Acute inflammation phase with limited ROM and instability on testing. Partial weight-bearing status is appropriate.

P:

Continue RICE protocol. Begin gentle ROM within the pain-free range. Taping for support. Educate on crutch use and weight progression. Recheck in 4–5 days.

7. Example SOAP Note For Sciatica

S:

Patient reports sharp, radiating pain from the lower back down the left leg to the calf. “It shoots down my leg when I sit too long or bend forward.” Pain is 7/10 and worsens with prolonged sitting. Describes occasional tingling in the left foot.

O:

ROM: Lumbar flexion limited to 30°, extension to 15° with pain.

Positive straight leg raise on the left at 40°. Decreased sensation in L5 dermatome. Strength: Dorsiflexors 4-/5 (left). Antalgic gait pattern noted.

A:

Findings indicate left-sided sciatica, likely due to lumbar nerve root irritation. Functional mobility is limited by pain and nerve sensitivity.

P:

Begin nerve gliding exercises and gentle lumbar extension movements. Avoid prolonged sitting. Educate on lumbar support and postural adjustments. Monitor neurological signs. Follow-up in 1 week.

8. Example SOAP Note For Chest Pain

S:

Patient reports dull chest discomfort for the past 2 days, aggravated by deep breathing and upper body movement. “It feels like a muscle strain, not sharp or radiating.” Pain rated 4/10. No shortness of breath or cardiac history. Denies nausea or dizziness.

O:

Palpation: Tenderness over left pectoral muscle and intercostal space. No swelling or bruising noted. ROM: Thoracic rotation and side bending limited by pain. Vitals: BP 122/78, HR 72, SpO₂ 98% on room air.

A:

Presentation consistent with musculoskeletal chest pain, possibly intercostal strain. No red flags for cardiac or pulmonary origin.

P:

Initiate gentle thoracic mobility drills and soft tissue release. Educate on activity modification. Monitor for any red-flag symptoms. Reassess in 3–5 days.

9. Example SOAP Note For Behavioral Health

S:

Patient reports increased anxiety and difficulty sleeping over the past 3 weeks. “My mind keeps racing, and I get overwhelmed even with small tasks.” Rates anxiety at 6/10 most days. No suicidal ideation. Appetite slightly decreased.

O:

Patient appears restless and speaks rapidly. Eye contact is inconsistent. Mood: anxious. Affect: constricted. Reports difficulty with focus during sessions. Oriented ×3.

A:

Generalized Anxiety Disorder (GAD) — symptoms include persistent worry, poor concentration, and physical restlessness. No immediate safety concerns.

P:

Introduce cognitive-behavioral techniques (CBT) focused on worry management. Recommend daily journaling and breathing exercises. Refer for medication evaluation. Follow-up next week.

10. Example SOAP Note For Counseling / Mental Health

S:

Client shares feeling emotionally “numb” and disconnected from friends. Reports lack of motivation, low energy, and occasional crying spells. Denies suicidal thoughts but expresses hopelessness about the future. Difficulty getting out of bed some mornings.

O:

Client presents with flat affect, slow speech, and minimal engagement. Eye contact is limited. Appears fatigued. Oriented ×3. Reports 3–4 hours of sleep per night and decreased interest in hobbies.

A:

Major Depressive Episode, moderate severity. Symptoms include anhedonia, low mood, insomnia, and withdrawal from social activities.

P:

Establish rapport and safety plan. Begin supportive talk therapy and explore thought patterns contributing to depressive symptoms. Assign behavioral activation tasks. Discuss referral to psychiatric services for further evaluation. Next session in 7 days.

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Common Mistakes to Avoid in Physical Therapy SOAP Notes

Even experienced clinicians can fall into autopilot with documentation.

But in physical therapy, vague or incomplete notes can misrepresent patient progress, create insurance denials, or weaken legal documentation.

Below are the most common mistakes I see when reviewing or teaching how to write physical therapy SOAP notes.

These apply whether you’re documenting a full evaluation, a quick progress note, or a post-surgical treatment session.

1. Vague or Generic Descriptions

Mistake: Writing things like “Patient better” or “Seems stronger.”

What to do instead: Always include specific, measurable changes in mobility, strength, or function.

Example: “Quadriceps strength improved from 4-/5 to 4/5 since last visit. Patient now able to perform 10 step-downs without pain.”

In PT SOAP notes, your Subjective and Objective sections must show clear, quantifiable progress, especially when justifying continued care.

2. Skipping the Functional Impact

Mistake: Describing symptoms without linking them to function.

What to do instead: Show how symptoms affect ADLs (activities of daily living), gait, work tasks, or recreational goals.

Example: “Pain with prolonged sitting impacts a patient’s ability to work full-time at a desk. Limits stair climbing beyond one flight.”

Physiotherapy is function-based care. Your notes should reflect that.

3. Leaving Out Objective Data

Mistake: Writing, “Knee ROM limited” without actual numbers.

What to do instead: Always document exact measurements using goniometers, strength grades, or standardized scores (e.g., Berg Balance).

Example: “Knee flexion: 105°, extension: 0°. Quadriceps strength: 4/5.”

Objective measures are what reviewers, insurers, and other clinicians rely on to interpret care.

4. No Clear Clinical Interpretation

Mistake: Jumping from observations straight to a plan, without tying it together.

What to do instead: Summarize what the findings mean for the patient’s diagnosis, impairments, and goals.

Example: “Pain during the step-down test suggests a persistent patellar tracking issue. Likely related to hip weakness and poor control in closed-chain tasks.”

Assessment is where your clinical reasoning should shine.

5. Unclear or Passive Plan

Mistake: Ending with “Continue therapy” or “Do exercises.”

What to do instead: Specify which exercises, how often, and what progression or reassessment is expected.

Example: “Add resistance band clamshells. Progress to single-leg squats by next visit. Continue 2x/week visits and reassess step-down tolerance in 7 days.”

Your plan should always reflect intentional progression and measurable targets.

Best Tool to Write SOAP Notes for Physical Therapy

Lindy is the best tool to write SOAP notes for physical therapy. It helps therapists draft clear, compliant documentation using AI, without losing clinical accuracy or personal voice.

Lindy’s AI scribe tools are built specifically for healthcare professionals. 

Whether you're in outpatient orthopedics or inpatient rehab, Lindy listens, structures, and summarizes the session in real time. 

You can dictate through your phone, upload notes, or even integrate with your EHR system. 

The result? 

Structured SOAP notes that reflect your care, not just a bunch of auto-filled templates.

Here’s what makes Lindy stand out:

• Real-time transcription and note structuring: Lindy captures your spoken or written notes and converts them into organized SOAP format—no manual re-typing required.
• Tailored for PT: You can define custom workflows like follow-up reminders, progress note tracking, and referral templates.
• Compliant and secure: Lindy meets HIPAA-grade data standards and keeps every record audit-ready.
• Cross-specialty support: If your practice includes chiropractic care, neuro rehab, or sports therapy, Lindy adapts to different SOAP frameworks with the same accuracy.

It’s not just fast, but it’s smart. Lindy uses context from previous sessions, current goals, and clinical impressions to help you produce better notes in less time.

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Frequently Asked Questions

1. Do all physical therapists have to use SOAP notes?

No. Not all physical therapists are mandated to use the SOAP (Subjective, Objective, Assessment, Plan) format for documentation. While SOAP notes are widely adopted due to their structured approach and clarity, alternative documentation methods exist and are utilized based on individual clinician preference, institutional policies, or specific clinical scenarios. 

2. How detailed should each section of a SOAP note be?

Each section should be comprehensive enough to convey the patient's status and the clinician's reasoning:

• Subjective: Capture the patient's reported symptoms, concerns, and experiences.
• Objective: Document measurable data such as test results, observations, and vital signs.
• Assessment: Provide a professional interpretation of the subjective and objective data, leading to a diagnosis or clinical impression.
• Plan: Outline the proposed treatment strategy, including interventions, goals, and follow-up plans.

The depth of detail should be sufficient to support clinical decisions and facilitate continuity of care.

3. Can I use templates for writing SOAP notes?

Yes, using templates can increase efficiency and ensure consistency in documentation. Templates serve as a guide, helping clinicians include all necessary information. However, it's crucial to personalize each note to reflect the individual patient's condition and treatment, avoiding generic or repetitive entries.

4. What are common mistakes to avoid in SOAP notes?

Common pitfalls include:

• Vagueness: Using non-specific language that doesn't clearly convey patient status or clinician observations.
• Omissions: Leaving out critical information that supports the assessment or plan.
• Redundancy: Repeating information across sections without adding value.
• Lack of clinical reasoning: Failing to connect subjective and objective data to the assessment and plan.

Avoiding these errors ensures the notes are informative, accurate, and useful for ongoing patient care.

5. How are SOAP notes used in legal or insurance audits?

SOAP notes serve as a legal record of patient care and are often reviewed during audits to verify the necessity and appropriateness of services provided. They must demonstrate that treatments are evidence-based and align with established clinical guidelines. Accurate and thorough documentation can support claims and protect against legal challenges.

6. How do I keep SOAP notes concise but compliant?

To maintain brevity without sacrificing compliance:

• Be specific: Use precise language and quantifiable data.
• Avoid unnecessary details: Include information relevant to the patient's current condition and treatment.
• Use bullet points: When appropriate, to organize information clearly.
• Review and edit: Ensure each section adds value and supports clinical decisions.

This approach keeps notes focused and informative.

7. Can AI help with writing SOAP notes?

Yes, AI tools can assist in drafting SOAP notes by organizing information and suggesting content based on input data. These tools can enhance efficiency and reduce documentation time. However, clinicians must review and edit AI-generated notes to ensure accuracy and relevance, as AI cannot replace professional judgment.

8. How often should SOAP notes be written?

SOAP notes should be completed after each patient encounter to document the session's findings and interventions. Timely documentation ensures accurate records, facilitates continuity of care, and supports billing processes.

9. What’s the best way to learn SOAP note writing?

The best way to learn SOAP note writing is:

• Studying examples: Review well-written notes to understand structure and content.
• Practicing regularly: Write notes consistently to build skill and confidence.
• Seeking feedback: Have experienced clinicians review your notes and provide constructive criticism.
• Continuing education: Participate in workshops or courses focused on clinical documentation.

10. Are there specialties within physiotherapy where SOAP notes are used differently?

While the SOAP format remains consistent, the content within each section may vary depending on the specialty:

• Orthopedic PT: Emphasis on musculoskeletal assessments and functional mobility.
• Neurological PT: Focus on neurological function, balance, and coordination.
• Pediatric PT: Consideration of developmental milestones and family involvement.

Each specialty tailors the SOAP note to address specific clinical considerations pertinent to their patient population.