In physical therapy, subjective, objective, assessment, and plan (SOAP) notes are used to record critical facts about a patient’s condition.
These notes discuss patient care from several perspectives and assist therapists in providing the care patients require. Learning about SOAP notes and how to write them may be beneficial if you work in physical therapy.
In this post, we will discuss the purpose of SOAP notes in physical therapy, how to write your SOAP notes, and provide an example of physical therapy SOAP notes.
What are SOAP Notes?
These meticulous notes track a patient’s progress throughout their treatment. Physical therapy SOAP notes are the most comprehensive and structured manner for a physical therapist to document patient progress.
These notes are meticulously kept in the patient’s medical records. Detailed patient notes are essential because they help keep communication between physicians running smoothly.
Furthermore, SOAP notes help to inform the Clinical Reasoning process. This is the “process by which a therapist engages with a patient, gathering information, creating and testing hypotheses, and establishing optimal diagnosis and treatment based on the information obtained,” according to Physiopedia.com.
What Does SOAP Stand for?
SOAP is an abbreviation for:
- Subjective
- Objective
- Subjective, Assessment, and
- Planning
The American Physical Therapy Association recommends the following information for Physical Therapist SOAP Notes:
- Factors influencing the intervention
- Progress toward specified objectives
- Communication with other healthcare practitioners, the patient, and their family.
- The patient’s self-report
- Specific intervention details Equipment utilized Changes in patient status
- Complications or severe reactions
SOAP is an acronym that stands for four critical aspects of patient documentation:
Subjective
SOAP notes’ subjective part highlights the patient’s perception of their condition, care, and progress. When diagnosing or tracking changes in a patient’s symptoms, medical personnel can benefit from the patient’s description of their experiences. This section may contain the following information:
- Level of activity
- Environmental considerations
- The degree of discomfort
- Mood
- When symptoms first appeared or worsened
The subjective component stresses the patient’s reaction to their situation. Physical therapists use details in this part to document how physical therapy treatments affect their overall quality of life. They may use subjective data to modify a care plan to boost patient morale and satisfy their requirements.
Objective
SOAP notes objective information that outlines actions and measurements connected to the patient’s treatment. In this section, physical therapists outline how they obtain factual information about patients and the outcomes of their procedures.
Listing objective details assists the physical therapist in determining progress with physical therapy treatments. Here are some examples of data to provide in the physical therapy objective section:
- Range of motion
- Strength level
- Ability to balance
- Tests of motor skills
- The vital signs
- Physical treatment exercises
- Treatment duration
- Equipment types
Assessment
Physical therapists review the patient’s condition and provide professional perspectives on the patient’s recovery status in the evaluation part. Physical therapists may review previous SOAP notes and notice changes to develop their assessment.
This component gathers and analyzes information from the prior two sections to forecast a patient’s healing and assess the effectiveness of their current treatment plan. SOAP notes’ assessment section may include the following:
- Patient behavior evaluation
- Changes in physical abilities explained
- Future progress projections
- Symptoms in brief
- Complications
- Interactions with other healthcare workers
Plan
The planning part is the final area of SOAP notes, where the physical therapist describes their planned treatment for future physical therapy sessions.
The physical therapist outlines home therapy, referrals to other specialists, recommended medications, and arrangements for the next in-person consultation.
Physical therapists explain their reasoning for each treatment element and any modifications from previous plans when describing their plan.
How to Write Physical Therapy SOAP Notes
To create detailed, practical SOAP notes for physical therapy, follow these steps:
1. Make individual notes
Use shorthand to take quick personal notes about your interactions and observations while treating patients. Because SOAP notes are detailed descriptions of physical therapy appointments, they necessitate concentration and attention.
Attempting to fill SOAP notes during treatment may distract you and the patient, so taking quick notes or making recordings can assist you in producing thorough records after the consultation.
2. Make use of a narrative format
Use a narrative structure to convey your results when filling out the key sections of the SOAP note. Explain the patient’s experience and what transpires during the session chronologically. The narrative approach connects each SOAP note to a larger story about the patient’s physical therapy treatment.
3. Concentrate on the facts
When describing your observations, be direct and objective. To avoid making assumptions about a patient or indicating judgments about their activities, attitude, or healing progress, maintain a neutral tone. Keeping your SOAP notes focused on the facts of a condition preserves their integrity as a medical document and allows a care team to make reasonable decisions.
4. Make use of precise terminology
Please include information about the patient’s appointment so that other healthcare practitioners may easily comprehend their medical records. Explain who performed each action, what equipment they used, and how you measured each action in detail.
Provide evidence for each point and carefully analyze the notes to ensure they are clear and logical. Refine any ambiguous language and order your thoughts to help the reader understand.
5. Determine therapy objectives
Begin your SOAP notes after a physical therapy session by writing down your goals for the patient. Goals add meaning to the notes and help you to assess a patient’s progress quickly. Use exact numbers to convey success indicators, such as walking 100 feet without assistance or lifting 15 pounds.
6. Keep the notes
Add the SOAP note to the patient’s file once completed. Keep track of the appointment date and the SOAP notes in chronological order. SOAP notes are most valuable when they are immediately accessible and may be used to reference how a patient’s physical abilities change in response to various therapies.
Physical Therapy SOAP Note Example
Use this example to learn how to prepare for beneficial physical therapy. SOAP notations:
Calliope Matthews is the patient’s name.
The date is May 16, 2021.
Dr. Kerry Neves is the provider.
Healing flexor tendon (post-surgery) in the left hand
Goals: Show an average grip strength of more than 10 pounds. Completing finger-tapping tasks with 80% accuracy is required.
-
Subjective
One month following tendon restoration surgery, the patient reports an overall discomfort level of 4/10 and growing sensitivity in his fingers.
She says she does radio-carpal abductions for 30 minutes every night, takes 400mg of ibuprofen twice a day, and splints her hand when not conducting a therapeutic activity.
“Not being able to play guitar is extremely terrible,” he says, expressing aggravation and depression about his lack of hand functionality. Denies having nausea, edema, or a temperature.
-
Objective
TENS unit was used to apply 40 minutes of nerve stimulation to the left hand, followed by 20 minutes of hand massage and finger mobilizations with the patient seated.
Three dynamometer grip tests were performed, yielding an average grip strength of 15 pounds at position two. Instructions for finger tapping were given with 75% accuracy.
-
Assessment
The patient’s strength and muscular function improve as a result of following splinting and exercise instructions. The patient fell short of the mobility recovery goal by 5% but has no other issues that would signal significant recovery delays.
Constant splint use may contribute to a slower improvement in mobility. By continuing the splinting and exercise routine, the patient should anticipate continuous gains in strength and mobility. Counseling may be beneficial in dealing with the stress of rehabilitation.
-
Plan
Continue radio-carpal abductions and add 10 minutes of tendon gliding exercises to your routine. Reduce splinting to solely at night to promote individual finger mobility.
After one week, repeat the finger-tapping exam. Make an appointment with a counselor who has been referred to you.
Benefits of Writing Physical Therapist SOAP Notes
There are numerous advantages to writing SOAP notes. Let’s go over some of the primary reasons these notes will be helpful to you:
Evidence of Interaction
Your Physical Therapist’s SOAP notes are particular and can readily serve as documentation of your interaction with any given patient regarding legality.
The written documentation contains the fundamentals, such as date, time, and location, and specific data that may become essential, such as the treatments you delivered, your professional assessments, and much more.
As a Physical Therapist, you may encounter patients who require additional documentation for legal reasons. For example, those injured in an accident caused by someone else, youngsters, incarcerated individuals, and so on.
Peer Information Exchange
When exchanging information among peers, SOAP notes are usually considered the most accurate medical record-keeping. Your Physical Therapist’s SOAP notes are essential to a patient’s overall care because they nearly always have additional providers on their care team.
When it comes down to it, creating SOAP notes provides your patients with evidence that their other caregivers can use to help them heal. This is very handy while working on a complex case.
Data Collection for Future Use
Medical professionals can construct their mini-research library by keeping meticulous treatment records. What works, what doesn’t, and everything in between will be noted.
Writing excellent Physical Therapist SOAP notes is a tested and accurate way of data collection. This information gives reference points throughout a patient’s journey, allowing you and your colleagues to treat future patients more accurately.
SOAP Note Template for Physical Therapy
Here’s a template to help you with your SOAP notes:
Patient name: [Full name of the patient]
Date: [The appointment date]
Providers[Names of physical therapists and helpers]
Diagnosis[Description of the patient’s existing conditions]
Goals[Explain the precise outcomes you hope to see in the patient during the session]
Subjective: [Describe the patient’s self-evaluation]
Objective[Summary of therapy and measurements administered]
Assessment[Assessment of the physical therapy appointment]
Plan: [Future therapy recommendation]
The Don’ts of Writing SOAP Notes
Subjective
The client indicated high motivation and participation. “I’m ready to work even harder today,” he added after finishing his schoolwork.
His mother said he was pleased to come to therapy today and had slept well the last few nights. His mother also said she did the at-home workouts with him every day this week, which she thinks is developing his confidence to work harder.
Avoid
Avoid unsourced opinions. In the example above, just saying “client was willing to participate” would be an opinion—and it’s unclear whose opinion—until you offer the client and his mother’s words to corroborate that observation.
Objective
This part records your observations of client behavior, the interventions used in the session, client responses to those interventions, and measurable results linked to your client’s performance, such as test scores, goal percentages, and other quantitative data.
Avoid
Avoid generalizations without evidence. The session impression “client responded well to non-verbal cues” needs more detail. Clinical actions should be clearly stated and linked to the treatment strategy. Avoid verbs like “discussed” or “explored” since their aim is unclear.
Assessment
This part summarizes your session analysis, interpretation, and client progress toward treatment plan targets. Compare performance to previous sessions and note strengths and weaknesses.
Avoid
Avoid rewriting the Subjective or Objective portions. This is where you look back at the client’s progress or regression and determine what caused it.
Plan
Outline immediate therapy steps for your client. List all altered actions, objectives, and reinforcements. If your client isn’t progressing, try a new approach.
Avoid
Avoid rewriting your treatment plan. This section should detail your next steps to help your client reach their treatment plan goal. If necessary, alter cues based on client progress.
Bottom Line
SOAP is an acronym for Subjective, Objective, Assessment, and Plan. Include the following items from the American Physical Therapy Association in your Physical Therapist SOAP notes to benefit you, your patient, and their entire care team:
- The patient’s self-report
- Specific intervention details
- Equipment utilized
- Changes in patient status
- Complications or severe reactions
- Factors influencing the intervention
- Progress toward specified objectives
- Communication with other healthcare practitioners, the patient, and their family
Writing SOAP notes ensures that everyone involved in your patient’s recovery gets the information they need to do their best.
