Free Template

SOAP Note Template for Physical Therapy

Physical therapists require detailed documentation for each treatment session. SOAP notes must demonstrate medical necessity, track measurable outcomes, and support insurance reimbursement. This template emphasizes functional outcome measures and objective data.

Blank Physical Therapy SOAP Note Template

Copy this template and fill in the bracketed sections with your session details.

SUBJECTIVE:
Patient reports [current symptoms/complaints]. [Functional limitations — e.g., difficulty with stairs, unable to reach overhead]. Pain rated [X/10] at [location]. [Change since last visit]. [Patient goals/concerns].

OBJECTIVE:
ROM: [joint, active/passive, measured in degrees]. Strength: [muscle group, MMT grade]. Special tests: [test name, positive/negative]. Functional measures: [standardized outcome measure and score]. Gait: [observations if applicable]. Treatment provided: [therapeutic exercises, manual therapy, modalities]. [Sets, reps, resistance, duration]. Patient tolerance: [good/fair/poor].

ASSESSMENT:
[Progress toward goals]. [Functional improvements or barriers]. [Clinical reasoning for treatment approach]. [Justification for continued treatment].

PLAN:
[Next visit focus]. [Exercise progression]. [Frequency/duration of remaining plan of care]. [Patient education provided]. [Coordination with other providers if applicable].

Filled Example — Physical Therapy

Here's what a completed SOAP note looks like for a physical therapy session.

SUBJECTIVE:
Patient reports continued right shoulder pain, rated 4/10 at rest and 7/10 with overhead reaching. States pain has improved from 8/10 at initial evaluation 3 weeks ago. Reports difficulty reaching into overhead cabinets and putting on a coat. Sleep is improving — now able to sleep on right side for short periods. Patient goal: return to recreational swimming within 8 weeks.

OBJECTIVE:
Right shoulder AROM: flexion 140° (155° last visit), abduction 130° (120° last visit), external rotation 45° (40° last visit), internal rotation 55° (50° last visit). Left shoulder AROM WNL for comparison. Strength (MMT): right shoulder flexion 4/5, abduction 3+/5, ER 3+/5, IR 4/5. Negative Neer's and Hawkins-Kennedy tests (previously positive at eval). Positive painful arc 80-120° abduction. DASH score: 38 (baseline 56). Treatment: ultrasound to right supraspinatus 5 min at 1.5 W/cm², manual therapy including posterior glide mobilizations (Grade III) to right GH joint, therapeutic exercise — standing ER with band (yellow, 3x12), sidelying ER (2 lb, 3x10), wall slides (3x15), scapular retraction with band (3x12), prone T's (2 lb, 3x10). Patient tolerated all exercises with good form.

ASSESSMENT:
Patient is making good progress toward goals. ROM improved in all planes, particularly abduction (+10°). DASH score improved by 18 points (clinically significant). Negative impingement signs suggest reduced subacromial irritation. Strength remains below functional threshold for overhead activities. Continued skilled PT is medically necessary to restore strength and full ROM for return to swimming.

PLAN:
Continue PT 2x/week for 4 more weeks (8 visits remaining on POC). Progress resistance on ER and abduction exercises. Introduce overhead strengthening next visit if pain-free arc continues to improve. Add sport-specific swimming motion exercises at week 6. HEP updated: add doorway pec stretch and sleeper stretch daily. Re-evaluate DASH and ROM at visit 12. Coordinate with orthopedist if plateau occurs.

Documentation Tips for Physical Therapy

Use measurable, objective data — degrees of ROM, MMT grades, standardized outcome scores
Compare current measurements to baseline and previous visits to show progress
Document specific exercises with sets, reps, resistance, and patient tolerance
Include standardized outcome measures (DASH, ODI, LEFS, etc.) to justify medical necessity
Your Assessment should provide clinical reasoning connecting findings to the treatment plan
Document functional improvements in patient-meaningful terms, not just clinical measures

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