Sample Physical Therapy Note

Posted By: David Mangusan Jr, BSPT, PTRP

Here is an example of a physical therapy (PT) SOAP note. In other countries, physical therapy is also called physiotherapy. I have included an example of a poorly written SOAP note here.

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.”

O =
VS:
BP = 120/80 mmHg
RR = 12 cpm
PR = 80 bpm
T^o = 37^o

Treatments provided:

1) Hot pack on lumbar area x 20 min. in prone.
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.

A = Patient tolerated treatment well and appears to be compliant with home exercise program.

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.

Suggested Readings: