Rehabilitation institutions may have different PT format but mostly use the widely accepted SOAP format. SOAP stands for subjective, objective, assessment/analysis, and plan.
A poorly written SOAP note for Low Back Pain:
S = Feel better.
O = Hot packs, TENS, US, Massage, Stretching
A = Tolerated well.
P = Continue
A more proper/functional SOAP note for Low Back Pain:
S = “Pain on my back has improved from pain scale of 7/10 to 3/10.”
BP = 120/80 mmHg
RR = 12 cpm
PR = 80 bpm
To = 37o
1) Hot pack on lumbar area x 20 min. in prone.A = Patient tolerated treatment well and appears to be compliant with home exercise program.
2) Deep kneading massage on lumbar paraspinal muscles x 5 min. in prone.
3) Ice pack on lumbar area x 20 min. in prone.
4) Prone lumbar extensions x 20 reps.
5) Educated patient on:a. Proper lifting techniques with 10 lb. box lift x 20 reps.
b. Proper sleeping techniques with emphasis on maintaining normal lumbar curve.
P = Continue with current treatment plan. Caution – patient needs frequent verbal cuing with proper lifting techniques.
The SOAP note should, of course, include basic information, such as the name of the patient; referring physician or doctor; date of treatment; and the name and designation of the physical therapist who provided the services. Signature, either manual or electronic, should also be included.
To Consider: Physical therapy SOAP note formats may vary in different institutions and settings.
- Physical Therapy Documentation
- Physical Therapy Initial Evaluation
- Writing Physical Therapy SOAP Notes (PT Notes) Basics
- Physical Therapy Documentation - PT SOAP Notes
- Physical Therapy Notes Writing Guidelines
- Parts of the Physical Therapy SOAP Notes