Parts of the SOAP Note
SOAP notes writing is divided into several parts:
The Subjective part is where patient /client information is written including history of present illness (HPI), past medical history, and family medical history.
Written on the Objective part of the SOAP are tests and measurements done on client, which include vital signs, range of motion (ROM) measurements, PT special tests, manual muscle tests, among others.
Information entered in the physical therapy SOAP Assessment section include list of client problems, goals (Short and Long-term goals if it is an Initial Evaluation) and physical therapist's impression or summary.
The Plan part includes details on the course of treatment that would address the specific client problems listed in the assessment area of your SOAP note.
SOAP Notes Books
Here are some helpful books on how to make an effective SOAP notes presented on our Amazon.com PT Notes Associates Store (Opens on a new window).
More About SOAP Notes
- Parts of the Physical Therapy SOAP Notes
- Writing Physical Therapy SOAP Notes Basics
- SOAP Note Example
- Physical Therapy Documentation
- Types of Physical Therapy Documentation