How to Write Incredible Physical Therapist SOAP Notes

In case you didn’t know, Physical Therapist SOAP notes are one of the most important tools in your arsenal.

What are SOAP notes?

These highly detailed notes are used to document patient progress throughout the course of their treatment.

While there are many ways a physical therapist can document patient progress, physical therapy SOAP notes are the most comprehensive and structured way to go.

These notes are carefully maintained within the patient’s medical records. Detailed patient notes are important as they help keep communication flowing seamlessly between providers.

In addition to that, SOAP notes serve to inform the Clinical Reasoning process. According to Physiopedia.com, this is the “process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.”

Let’s learn more about how SOAP notes got their origin.

What Does SOAP Stand For?

Did you know SOAP notes were developed in the 1960’s by Dr. Lawrence Weed? Back then, the common documentation approach was more general and less detailed.

During his time at the University of Vermont, Dr. Weed began writing patient notes based on individual problems and ailments.

These “Problem-orientated medical records (POMR)” included details about:

The patient’s specific problems
The therapist’s desired outcomes
A diagnosis if applicable
Treatment plan details

Because the POMR acronym wasn’t quite so catchy, Dr. Weed revised it to SOAP.

SOAP stands for:

Subjective,
Objective,
Assessment
and Plan.

The American Physical Therapy Association provides general guidance on what information should be included in Physical Therapist SOAP Notes:

Self-report of the patient
Details of the specific intervention provided
Equipment used
Changes in patient status
Complications or adverse reactions
Factors that change the intervention
Progression towards stated goals
Communication with other providers of care, the patient and their family

Now that you have a general idea of what a SOAP note consists of, let’s take a more detailed look at each section.

How to Write Physical Therapy SOAP Notes

Physical Therapist SOAP notes include four sections, each with a uniquely important function.

S – Subjective

As all health professionals know, it is incredibly important to understand what a patient is experiencing from their point of view. Documenting their subjective experience is crucial because it provides insight into so many aspects of their healing process, such as:

How they feel about their progress
If they are able to function and on what level
How/if their quality of life improves over time

Some patients may not have strong opinions on their treatment, but many do. Notes in this section should also include the patient’s opinions on how and/or why they will overcome their ailment.

When applicable, taking subjective opinions from caregivers and/or family members proves useful as well.

Remember: it’s important to document how the patient perceives their situation without coloring it with your observations or assessments. Your observations come next, and your professional assessment goes in a later section.

O – Objective

The next step in writing SOAP notes focuses on your objective observations.

In this section, the therapist includes detailed notes on current patient status and treatments.

Specifically, therapists should document patient measurements (range of motion, vitals) as well as individual treatment interventions such as:

Frequency
Duration
Equipment used

While this section doesn’t bear as much weight from the legal documentation standpoint, it is highly relevant in the actual treatment of your patient. This section should be specific enough that any other healthcare professional could pick up where you left off.

A – Assessment

This section is of high importance when it comes to the legal obligation therapists have regarding documenting patient progress.

Most importantly, you must state and explain your reasoning for all diagnosis and treatments. Make an effort to show:

How you reached your opinion based on the two previous sections
Why you made the specific treatment decisions based on the patient’s unique problem.
How you intend to work with the patient on their journey (goals) and any factors that affect these goals.

Whereas the observation section is objective, the assessment section provides the therapist a place to record their professional take on each session.

P – Plan

The final step in writing SOAP notes is documenting the development of your patient’s treatment plan. Specifically, what do you intend to do in future sessions?

Use this area to cover any potential upcoming treatments as well as patient homework before the next sessions.

Even if the next session will be exactly the same, refrain from simply noting “continue with treatment”. Vague SOAP notes won’t help you or your patient’s care team, so take a few minutes to report any steps you plan to cover.

Finally, if you intend to modify your treatment, this is the section to note that.

A Physical Therapy SOAP Note Example

Let’s take a look at a detailed physical therapy SOAP note example. We’re quoting this one from the book “Functional Outcomes – Documentation for rehabilitation” found on page 125.

It can take some time to write SOAP notes, but you can now see why it is certainly worth the effort.

Benefits of Writing Physical Therapist SOAP Notes

As you can imagine, there are endless benefits for writing SOAP notes. Let’s review some of the main ways these notes will help you:

1. Proof of Interaction

From a legality standpoint, your Physical Therapist SOAP notes are very specific in nature and can easily serve as proof of your interaction with any given patient.

The written documentation not only covers the basics such as date, time and location but also covers certain details that may become relevant, like the types of treatments you provided, your professional assessments and much more.

As a Physical Therapist, you may work with patients who require an extra level of documentation for legal purposes. For example, those who suffered injuries in an accident caused by someone else, minors, people who are incarcerated, and so on.

2. Data Collection for Future Reference

Creating a record of detailed treatment notes allows a medical professional to build their own mini-research library. You will note what works, what doesn’t and everything in between.

Writing great Physical Therapist SOAP notes is a tried and true method for collecting data. This data provides reference points throughout a patient’s journey that can help you and your colleagues treat future patients with better accuracy.

3. Information Sharing Among Peers

Speaking of better accuracy, SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. Your Physical Therapist SOAP notes play a big role in the overall care of a patient who almost always has other providers on their care team.

When it comes down to it, writing SOAP notes gives your patients documentation their other caregivers can use to aid in the healing process. This is especially useful when you are working on a complicated case.

Conclusion

SOAP stands for Subjective, Objective, Assessment and Plan.

If you want to write Physical Therapist SOAP notes that help you, your patient and their whole care team, include these elements outlined by the American Physical Therapy Association:

Self-report of the patient
Details of the specific intervention provided
Equipment used
Changes in patient status
Complications or adverse reactions
Factors that change the intervention
Progression towards stated goals
Communication with other providers of care, the patient and their family

Writing SOAP notes ensures everyone involved in your patient’s recovery has the information they need to do the best job possible.

Do you have any tips for writing incredible Physical Therapist SOAP Notes?

Share them with us in the comments below!

Author

Aaron Stanley

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