Writing Physical Therapy SOAP Notes Basics

The physical therapy notes (PT Notes) is a particular format of recording information employed by physical therapists. Most PT notes are written in the S.O.A.P note format, which stands for Subjective, Objective, Assessment and Plan. It is a record of the progress of the patient, which is included in his or her patient chart.

SOAP Notes Parts

Subjective

The information contained in the subjective part of the PT note includes what the patients says about his or her condition or problem. It can be in the form of a quote from the patient's statement, for example, "My back is so painful, especially after sitting for many hours at work."

It is better to look for subjective information that is more specific, such as "My back pain has reduced from 10 to 6." Or it can be stated as "Patient states that his back pain has reduced from pain level of 10 to 6."

It is important that in this section, the subjective information should be related to the patient's condition, progress in rehabilitation, functional mobility or quality of life. Other irrelevant information should be excluded, such as "Brittney's bald again."

Objective

This section of the PT note is where concrete measurements, such as blood pressure and range of motion and treatment interventions performed are recorded. This section should include specific treatments. It should also include the frequency, duration and equipment used.

The objective section should be specific enough so that in case the therapist is not available, another therapist can treat the patient.

Assessment

This is where the impression of the physical therapist is recorded regarding the patient's performance during the treatment procedure. "The patient tolerated the treatment well" statement is commonly used, but it's not telling whether or not the client is progressing throughout the overall treatment plan.

Plan

This is the final section of the physical therapy note. It is where the physical therapists would outline the course of treatment after considering the information he or she has gathered during the treatment session. If the therapist would like to continue treatment following the original plan of the care, the PT might just say "Continue with current plan."

Writing physical therapy SOAP notes is an invaluable documentation that every physical therapy student should learn. Students learning how to write SOAP notes also need to learn how to write physical therapy abbreviations. Some of these basic abbreviations are enumerated at our PT Abbreviations Page.


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References:
Guidelines: Physical Therapy Documentation of Patient/Client Management. American Physical Therapy Association (APTA) from http://www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=31688. Accessed June 24, 2010.

Karen McComas (n.d.). DAILY PROGRESS NOTES: SOAP Note Format from http://people.ehe.ohio-state.edu (pdf format). Accessed June 24, 2010.