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:
- The SOAP acronym
- A step-by-step SOAP guide
- A physical therapy SOAP note example – or two
- How an AI medical scribe can save you hours every day
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:
- Better communication: They provide a standardized format for a clear exchange of key details among therapists, chiropractors, and other healthcare professionals.
- Treatment optimization. Detailed SOAP notes enable therapists to track progress, adjust interventions, and tailor plans for the best possible outcomes.
- Billing and reimbursement. Accurate SOAP notes form the basis for insurance claims and ensure the proper reimbursement in the case of a mishap.
- They provide a clear picture of patient care. SOAP notes offer a documented record of care delivery, vital for legal and ethical considerations.
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.
- The main reason for seeking physical therapy.
- The onset, duration, and progression of their symptoms.
- Their clinical history, including relevant medical conditions and previous treatments.
- The actual effect. How symptoms affect daily activities.
- Goals! What the patient hopes to achieve with therapy.
Example:
- Chief complaint: "Pain in my left knee when walking and climbing stairs."
- History of present illness: "Started a week ago after a rough game of hockey. Pain is sharp and worsens when I try to walk."
- Past medical history: No surgeries or major medical conditions.
- Functional limitations: "Difficulty walking long distances and climbing stairs. Having trouble squatting to reach low objects."
- End-goals and expectations: "Want to be able to return to basketball pain-free and regain full mobility in my knee."
Tips:
- Try to use direct quotes whenever possible.
- Try to focus on relevant details that contribute to the physical therapy diagnosis and treatment plan.
- Be empathetic and patient – you are the patient’s safe space.
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:
- Gait and posture: Observe the patient's walking pattern and overall posture.
- ROM: Measure the movement capabilities and range of motion of the affected joints.
- Muscle strength and tone: Assess muscle strength and any abnormal muscle tightness or weakness.
- Palpation: Identify any tenderness, swelling, or joint effusion.
- Special tests: Perform specific tests related to the suspected diagnosis.
Example:
- Gait and posture: Limping slightly on the left leg, slight flexion of the left knee during stance.
- Range of motion: Right knee flexion limited to 70 degrees (normal: 120 degrees).
- Muscle strength: Quadriceps strength on the right leg is significantly weaker than the left.
- Palpation: Tenderness around the medial aspect of the right knee with a slight effusion.
- Special tests: The McMurray test is positive for meniscal tear.
Tips:
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:
- Differential diagnosis: List possible causes of the patient's symptoms based on the collected information.
- Functional impact: Describe how the condition affects the patient's ability to perform daily activities.
- Prognosis: Predict the expected course of recovery and potential outcomes with treatment.
- Precautions and contraindications: Now it’s time to identify any factors that may limit treatment options or pose safety risks.
Example:
- Differential diagnosis: Meniscal tear, medial patellofemoral pain syndrome, patellofemoral instability of the left knee.
- Functional impact: Difficulty walking and climbing stairs, negatively impacting work and recreational activities.
- Prognosis: Full recovery expected with appropriate physical therapy and the potential need for further investigation if there’s no improvement after initial treatment.
- Precautions and contraindications: Avoid activities that exacerbate pain, and consider bracing for patellar tracking if instability is confirmed.
Tips:
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:
- Treatment interventions: Describe the planned exercises, modalities, and manual therapy techniques the patient will need.
- Home exercise program (HEP): Give them clear instructions for exercises they can perform independently. If you can link to videos, all the better.
- Counseling and education: Talk to the patient about their condition, pain management strategies, and activity modifications.
- Follow-up plan: Determine the frequency of future appointments and any necessary reevaluations. The patient from this physical therapy SOAP note example may be seeing you often!
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.
Plan:
- Treatment interventions: Manual therapy techniques for trigger point release and mobilization of the lumbar spine, therapeutic exercises focused on core strengthening and spinal mobility, and modalities like heat and ultrasound for pain relief.
- Home exercise program (HEP): Daily exercises for maintaining lumbar spine flexibility and strengthening core muscles, proper bending and lifting techniques education.
- Education and counseling: Importance of maintaining good posture, ergonomic adjustments at work, activity pacing and modification strategies.
- Follow-up plan: Re-evaluation in 2 weeks to assess progress and adjust treatment plan as needed.
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.
Plan:
- Treatment interventions: Ice and ultrasound for initial inflammation control, gentle stretching and strengthening exercises specific to the rotator cuff muscles, manual therapy techniques for capsular mobility, and pain management.
- Home exercise program (HEP): Daily exercises for rotator cuff strengthening and scapular stabilization, instructions on proper throwing mechanics and activity modification strategies.
- Education and counseling: Importance of avoiding aggravating activities, proper warm-up and cool-down routines for shoulder health, and ergonomic adjustments at work if applicable.
- Follow-up plan: Re-evaluation in 3 weeks to assess progress and adjust treatment plan as needed.
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:
- Voice dictation with auto-transcription: Ditch the keyboard and dictate your notes seamlessly. Lindy's AI Assistant accurately transcribes your words in real-time, automatically formatting them into the SOAP structure.
- Pre-populated templates: Save time with customizable templates based on common diagnoses and interventions. Simply choose the relevant template and tailor it to the specific patient.
- Automatic data capture: Integrate your EHR system with Lindy to automatically pull in relevant patient data, eliminating manual data entry and minimizing errors.
- Instant insights and recommendations: Generate reports and gain valuable insights into patient progress and treatment trends. Lindy can even suggest tailored interventions based on data analysis.
- Streamlined billing and reimbursement: Accurately capture and document billable services with ease, ensuring streamlined claims processing and faster reimbursement.
Using Lindy isn't just about saving time, it's about enhancing your practice:
- Focus on what matters: By delegating documentation tasks to AI, you can prioritize quality patient interactions and personalized care.
- Improved accuracy and consistency: Lindy's AI technology minimizes errors and ensures consistent formatting and terminology in your SOAP notes.
- Fully HIPAA-compliant: for your peace of mind. Patient information is always safe and secure.
- Enhanced data-driven decision-making: Gain valuable insights from your data and make informed decisions about treatment plans and overall practice management.
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!
