It is essential for physical therapists to keep track of patient information, monitor their progress, and communicate this information with other health care providers to facilitate both interdisciplinary and intradisciplinary care. One common method of documentation that can accomplish these objectives is called the SOAP note.
What do the letters in SOAP stand for and how do you write a SOAP note? We will break the process of how to write a SOAP note into digestible sections in this piece and explain how PTs should go about doing so.
The main purpose of SOAP notes is that they serve as a standardized documentation format that allows physical therapists and other healthcare professionals to record, analyze, and plan for each patient’s care.
A physical therapy SOAP note is critical because it helps maintain comprehensive records, ensure accountability, and facilitate communication with other healthcare professionals.
Improved note taking efficiency is possible through Electronic Medical Record (EMR)+ software that contains advanced note taking and data management features.
The subjective section of the SOAP note is where the patient’s perspective comes into play.
The subjective section allows physical therapists to provide patients with a chance to tell their story. Information within this section may include:
One good mnemonic to use for the subjective section is OLDCART. Below are the explanations of what each letter stands for, along with examples:
Effective communication and active listening are key for mastering the subjective section. Using phrases such as “If I am understanding correctly, you are saying ____,” or attempting to rephrase what they patient has just stated allows for clarification and minimizes the possibility of miscommunication.
Given the volume information that can be placed into a subjective section, formatting these notes in a predetermined template within physical therapy management software can facilitate efficient, effective note taking.
Below is one SOAP note example of a subjective section that may appear for a follow-up visit of a patient seen for right knee osteoarthritis.
“Patient states that she has done the exercises three times since her last visit. She is having trouble with one of the exercises and is not sure if she is performing it correctly. Pain level in her right knee is a 3/10 today and felt slightly achy this morning. The achiness has decreased as she has moved around more throughout the morning. Squatting and descending steps are still the most aggravating movements, and cause 5/10 pain level. Patient is now able to walk for 10 minutes before she develops any knee pain. She would like to be able to walk up to 30 minutes three times per week for exercise with minimal pain.”
Physical therapy evaluation subjective sections may appear much longer and more detailed, as they would include more of the information covered in the preceding section, such as medications, allergies, and medical history.
While the subjective portion of the note brings the patient’s story to the forefront, the objective section brings precision to your documentation.
Physical therapists must gather objective data, including range of motion assessments, strength tests, gait and posture analysis, girth/swelling, wound or incision integrity, special tests, and more.
Precision and consistency in measurements are key. Note the position a patient was placed in for tests and measurements. Consider using a symbol such as an asterisk marked in a key to denote whether a patient experiences pain or discomfort with any objective measurements. These can help to reassess the patient more accurately at the time of progress notes or discharge by ensuring the testing setup is duplicated.
Effective use of visual aids such as graphs and charts can enhance the objectivity of SOAP notes.
For example, including a bilateral manual muscle test (MMT) or range of motion (ROM) chart allows the therapist to utilize MMT grades from 0 to 5 for each muscle or movement. Additional columns may be added to allow the therapist to make other notes on any compensations or check if there is pain while testing certain movements.
Dermatome, myotome, and reflex charts may be placed in the objective section as well. Girth charts for swelling may appear here, too. Make note of the landmarks where the girth is measured, such as the superior and inferior poles of the patella.
If any special equipment is utilized, such as isokinetic testing or force plates for gait and running analysis, the computer-generated graphs can help provide quantifiable information.
These visual aids provide a holistic view of a patient's condition by comparing differences in strength and ROM for certain muscles or movements from one side to another. They also allow for effective comparison between different time points.
In this section, we'll guide you through the process of clinical assessment.
The assessment section elaborates on the process of assessing a patient's progress and condition using the combined information from the subjective and objective sections.
Some examples of what may be included in this section are:
Emphasize the importance of clinical reasoning and critical thinking in the assessment section to help justify the necessity of physical therapy services for improving a patient’s function and meeting their goals.
Physical therapists establish measurable treatment goals based on their assessment.
Goals should follow the SMART (Specific, Measurable, Achievable, Relevant, Time-bound) framework to meet quality standards and assist in justifying necessary physical therapy services to insurance companies and other healthcare providers.
The plan section outlines the path to recovery.
The formulation of a treatment plan should encompass specific interventions, modalities, therapeutic exercises, and strategies that will be used to achieve a patient’s goals. Specify any relevant techniques, such as manual therapy and education, that may be provided throughout a patient’s plan of care.
Each patient is different, and individualized plans are needed to tailor to each patient's unique needs. Two patients with the same diagnosis or condition may need different interventions, or varied amounts of certain interventions depending upon their psychosocial, physical, and environmental factors.
Effective patient communication in the plan section will help patients understand what services physical therapy offers and the types of interventions they can expect to receive throughout their plan of care. This is also a great chance to educate patients on the scope of practice physical therapists hold.
Therapists should ensure patients understand the recommended interventions and are aware of how they should be actively participating in their rehabilitation journey.
Effective documentation is the backbone of healthcare.
Timely and accurate documentation is critical for adherence to legal and ethical standards in physical therapy practice.
Physical therapists must consider the legal and ethical considerations related to patient records and confidentiality. Protected health information (PHI) should not be shared with those who are not involved in a patient’s care. Passwords should be strong and include different characters, capitalizations, and be a certain minimum length for best practice. Do not share access to your documentation with anyone and only access it over secure Wi-Fi so there is less risk of a data breach.
Consider what is relevant to document in the note, as some information the patient provides may not be necessary to include. Do always include information that may impact a patient’s safety and clearly state the actions you took to help the patient and keep them safe. Note whether additional communication with outside resources or providers was recommended to the patient or performed by the physical therapist.
As a healthcare provider, the physical therapist plays a role in safeguarding sensitive information.
Utilizing software like PtEverywhere helps physical therapists document SOAP notes and manage patient data to streamline the treatment process. It is incredibly useful for efficiency and practice management as it can help take some of the stress off documenting and shift the focus toward patient-centered care.
SOAP notes are more than documentation—they’re essential for improving patient care and clinic efficiency.
Enhancing Patient Care: Detailed SOAP notes provide a clear treatment plan and track progress, enabling tailored therapies that improve outcomes.
Improving Communication: Accurate notes ensure seamless collaboration between healthcare providers, reducing errors and enhancing care quality.
Streamlining Operations: Thorough documentation simplifies billing, ensures smoother insurance claims, and saves time by reducing errors.
Boosting Legal Credibility: In audits or disputes, comprehensive notes demonstrate professionalism and justify the necessity of treatments.
While SOAP notes are a valuable tool, there are common mistakes that can hinder their effectiveness. Here are some key areas to watch out for:
By avoiding these common errors, physical therapists can create clear, concise, and informative SOAP notes that effectively communicate patient status and progress.
Electronic Medical Records (EMR) software like PtEverywhere can significantly streamline SOAP note creation. These tools offer features like:
PtEverywhere, specifically designed for physical therapists, offers additional functionalities like outcome measure libraries and progress reports, further simplifying SOAP note documentation. These features empower therapists to focus on patient care while ensuring well-documented and comprehensive SOAP notes.
What are SOAP notes? They are a uniform method of documentation within the physical therapy and medical fields that include subjective, objective, assessment, and plan sections. Knowing what each section entails and how to write a SOAP note is essential for clear communication within the physical therapy field.
Mastering SOAP notes can elevate patient care, streamline documentation, and support interdisciplinary collaboration. So, if you've been wondering how to write SOAP notes, we've got you covered! EMR software such as PtEverywhere is useful for simplifying the SOAP note for physical therapists creating clear and concise documentation.
Try out PtEverywhere today by signing up for a demo!
SOAP stands for Subjective, Objective, Assessment, and Plan. These are the four key sections used to organize patient information in a SOAP note.
SOAP notes are important because they provide a standardized method for documenting patient information, which enhances communication among healthcare providers, ensures continuity of care, and supports the evaluation of patient progress.
SOAP notes should be updated at every patient visit. Timely and accurate documentation ensures that all relevant information is recorded and that patient care is well-coordinated.
The Subjective section should include the patient’s perspective on their condition, including their symptoms, pain levels, and any changes since the last visit. It also includes personal information such as patient goals, medical history, and lifestyle factors.
The Objective section records measurable and observable data, such as range of motion, strength tests, gait analysis, posture assessments, and any other relevant physical examination findings.
To ensure a thorough Assessment section, integrate findings from the Subjective and Objective sections, use clinical reasoning to interpret the data, and clearly document any progress, setbacks, or changes in the patient’s condition. Setting specific goals can also enhance the clarity and effectiveness of this section.
A good Plan section should outline the specific interventions and strategies to be used, including therapeutic exercises, manual therapy, patient education, and any other relevant treatments. It should also include the frequency and duration of these interventions, as well as any follow-up plans.
Yes, SOAP notes can be used for legal purposes as they provide a detailed and accurate record of patient care. It’s important to ensure that all documentation is complete, accurate, and adheres to legal and ethical standards.
Yes, there are legal requirements for SOAP note documentation. These include maintaining patient confidentiality (e.g., complying with HIPAA regulations in the US), accurately recording patient information, and ensuring that notes are complete and updated regularly.
EMR software can improve SOAP note documentation by providing templates, automating data entry, ensuring consistent formatting, integrating with diagnostic equipment, and offering tools like dictation and auto-population. This can save time and enhance accuracy.