SOAP Note Example
Physical Therapy SOAP Note Example
Below is a complete SOAP note example for a physical therapy session treating a patient 6 weeks post-operative left ACL reconstruction with patellar tendon autograft. This example demonstrates proper documentation of objective measurements, functional assessments, and evidence-based treatment planning for post-surgical rehabilitation.
Complete Physical Therapy Note
SUBJECTIVE:
Patient is a 28-year-old male, 6 weeks status post left ACL reconstruction with patellar tendon autograft (Dr. Moreno, 01/17/2026). This is visit 10 of 24 authorized. Patient reports left knee pain rated 3/10 at rest, increasing to 5/10 with prolonged standing and after therapy exercises. Describes stiffness in the morning lasting approximately 20 minutes, improving with gentle movement. States he is performing his home exercise program daily without significant difficulty but notices the knee swells slightly after stationary bike sessions. Reports improved confidence with weight bearing since last visit — now ambulating with a single-point cane indoors and using bilateral axillary crutches outdoors on uneven surfaces only. Sleep is minimally disrupted — wakes once per night when rolling onto left side. Denies giving way, locking, or catching. Denies numbness or tingling. Patient goals: return to recreational basketball within 9 months, return to full-duty work as a warehouse associate (requires lifting up to 50 lbs, frequent squatting, and standing for 8-hour shifts) within 4 months.
OBJECTIVE:
Observation: mild effusion left knee, no erythema or ecchymosis. Surgical incision sites well-healed, no drainage or dehiscence. Gait: antalgic pattern with decreased left stance phase and mild quadriceps avoidance gait noted; ambulating with single-point cane in right hand. Goniometry (left knee): active ROM flexion 105 degrees (right 140 degrees), passive ROM flexion 112 degrees (right 142 degrees), active ROM extension -3 degrees (right 0 degrees), passive ROM extension 0 degrees (right 0 degrees). Girth measurements: 2 cm above superior patellar pole — left 42.5 cm, right 45.0 cm (2.5 cm deficit); 6 cm above superior patellar pole — left 48.0 cm, right 51.5 cm (3.5 cm deficit indicating continued quadriceps atrophy). Manual Muscle Testing (left/right): quadriceps 3+/5 / 5/5, hamstrings 4/5 / 5/5, hip abductors 4/5 / 5/5, hip extensors 4-/5 / 5/5, hip adductors 4/5 / 5/5, ankle dorsiflexors 5/5 / 5/5, ankle plantarflexors 5/5 / 5/5. Patellar mobility: grade 2 superior glide (mildly restricted), medial and lateral glides within normal limits. Special tests: Lachman test — firm end feel, 1-2 mm translation (grade 1A, stable graft); anterior drawer — negative; McMurray — negative. Effusion: trace to mild (stroke test positive medial, minimal fluid wave). Functional assessment: single-leg stance left 12 seconds (right 30+ seconds), sit-to-stand from 18-inch surface completed with minimal upper extremity assist, step-up 6-inch step completed with good alignment but compensatory trunk lateral lean, Y-Balance Test not yet administered (deferred to week 10 re-evaluation). Treatment provided this session: stationary bike warm-up 10 minutes (low resistance, pain-free ROM), patellar mobilizations grade III superior and inferior glides (5 minutes), quadriceps isometrics with EMG biofeedback at 0 degrees, 30 degrees, and 60 degrees knee flexion — 3 sets of 10 with 10-second holds, straight leg raises supine 3 sets of 15 with 1 lb ankle weight, standing hamstring curls 3 sets of 12 (yellow Theraband), mini squats 0-45 degrees with ball squeeze for VMO activation 3 sets of 10, heel slides supine with towel assist for flexion ROM 3 sets of 15 repetitions, standing hip abduction with red Theraband 3 sets of 12, prone hip extension 3 sets of 10, balance training on firm surface — single-leg stance with manual perturbations 3 sets of 30 seconds, cryotherapy with compression wrap 15 minutes post-treatment. Total treatment time: 55 minutes.
ASSESSMENT:
Patient is 6 weeks post left ACL reconstruction (patellar tendon autograft) progressing within expected parameters per post-operative rehabilitation protocol. Key findings: knee flexion ROM at 105 degrees active (protocol target by week 6 is 110-120 degrees) — slightly behind target; extension ROM at -3 degrees active but achieving 0 degrees passive — near goal, and active extension deficit is likely due to quadriceps inhibition rather than structural limitation. Quadriceps strength remains the primary impairment — 3+/5 MMT with a 3.5 cm girth deficit reflects significant continued atrophy and is the primary driver of the antalgic gait pattern, compensatory movement during step-ups, and reduced single-leg stance time. Graft stability is excellent (Lachman grade 1A, anterior drawer negative). Trace effusion is manageable and does not suggest a complication — consistent with post-exercise inflammatory response. Functional deficits in single-leg balance (12 seconds vs 30+ contralateral), step-up quality, and sit-to-stand independence are directly linked to the quadriceps and hip extensor weakness. Patient is motivated, compliant with his home exercise program, and demonstrates good understanding of precautions, which supports a positive prognosis. Current status warrants continued skilled physical therapy — patient requires hands-on patellar mobilization, EMG biofeedback for quadriceps re-education, balance training with perturbations, and supervised exercise progression that cannot be safely self-directed at this stage. Patient is cleared to advance to Phase III (progressive strengthening and early neuromuscular control) per protocol.
PLAN:
Continue physical therapy 3x/week for the next 4 weeks, then reassess for frequency reduction to 2x/week based on progress. Phase III goals (weeks 6-12): achieve full active knee extension (0 degrees), flexion ROM to 130 degrees, quadriceps MMT 4/5 or greater, thigh girth deficit less than 1.5 cm, discontinue assistive device for all community ambulation, and normalize gait pattern. Exercise progression this phase: advance closed kinetic chain exercises — wall squats progressing to parallel depth, bilateral leg press beginning at 50% body weight and advancing by 10% weekly, step-ups progressing from 6-inch to 8-inch then 10-inch height over 4 weeks. Initiate eccentric quadriceps loading with slow descent squats (4-second lowering phase, 3 sets of 8). Progress balance training to unstable surfaces (foam pad at week 7, BOSU at week 9). Begin aquatic therapy 1x/week if pool available — pool walking, bilateral squats, and flutter kick (no breaststroke kick until week 16). Continue patellar mobilizations until superior glide normalized. Home exercise program updated: add prone heel hangs for terminal extension with 2 lb ankle weight (5 minutes, 2x daily), wall slides for flexion ROM (3 sets of 15, 2x daily), quad sets with towel roll under knee (3 sets of 20, 3x daily), standing calf raises bilateral (3 sets of 15, daily). Ice and elevation 15-20 minutes after all exercise sessions. Formal re-evaluation scheduled at week 10 including goniometry, girth measurements, MMT, Y-Balance Test, and Lower Extremity Functional Scale (LEFS) outcome measure. Contact referring surgeon Dr. Moreno if flexion ROM does not reach 120 degrees by week 8 or if effusion increases beyond mild grade.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
In a physical therapy SOAP note, the subjective section captures the patient's self-reported pain levels, functional status changes since the last visit, and their experience with their home exercise program. Include the surgical date, surgeon name, and procedure for post-operative cases — this establishes the clinical timeline that insurance reviewers need. Document specific functional milestones like assistive device progression (bilateral crutches down to single-point cane) because these show measurable improvement. Include the patient's personal goals (return to sport, return to work with specific demands) because these drive the plan of care, inform discharge criteria, and help justify the duration of skilled therapy.
Objective
Physical therapy documentation requires precise, reproducible measurements — not subjective descriptors like 'limited' or 'weak.' Goniometry values in degrees, girth measurements in centimeters, and MMT grades on the 0-5 scale give you quantifiable baselines to track progress over time. Always compare to the contralateral (uninvolved) side to establish the patient's individual normal. Include special tests (Lachman for ACL graft integrity, McMurray for meniscus) and functional assessments (single-leg stance time, sit-to-stand performance, step-up quality) because these bridge impairment-level data to real-world functional capacity. Document every exercise with sets, reps, resistance, and any modifications or cues provided. This level of specificity demonstrates skilled intervention, defends against insurance audits, and allows any covering therapist to replicate the session exactly.
Assessment
The assessment is your clinical reasoning on display. Compare the patient's current status to protocol benchmarks (flexion ROM slightly behind the week 6 target of 110-120 degrees), identify the primary impairments driving functional limitations (quadriceps atrophy causing compensatory gait pattern and reduced balance), and state whether the patient is progressing as expected. This section is where insurance utilization reviewers look to determine medical necessity — you must explicitly connect impairments to functional deficits and explain why skilled physical therapy, rather than a home program alone, is still required. State the specific skilled services that justify continued visits (manual mobilization, biofeedback, supervised progression).
Plan
The plan should include treatment frequency with a clear reassessment timeline, specific exercise progressions with parameters (resistance, height, sets/reps), updated home exercise program instructions, and measurable goals with target dates tied to the protocol phase. For post-operative patients, reference the rehabilitation protocol phase so any reviewer can verify the progression is appropriate. Include the specific outcome measures you will administer at re-evaluation (LEFS, Y-Balance Test, goniometry) and define clear escalation criteria — such as when to contact the surgeon — so that any provider reviewing the chart understands the clinical decision framework. This demonstrates that care is goal-directed and time-limited.
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