Physical therapy SOAP note example

A daily treatment note for an outpatient physical therapy visit after knee surgery. It records the patient's report, measurements against the evaluation, the interventions with their minutes, and progress toward short- and long-term goals.

Example SOAP note

Fictional patient: David K., 52, five weeks after a right partial medial meniscectomy, visit 6 of 12. Any likeness to a real person is a coincidence.

Subjective

Patient reports right knee pain 3/10 at rest and 5/10 going down stairs (6/10 and 8/10 at evaluation). Walking 20 minutes on level ground without an increase in pain.

Still uses the handrail to go down stairs at home. Doing his home exercise program once a day. Goal: return to recreational tennis.

Objective

Knee AROM: right 0–125° flexion (evaluation 5–105°); left 0–140°.

Effusion: trace on the stroke test, right knee.

Manual muscle test: right quadriceps 4/5, left 5/5.

Single-leg stance: right 20 seconds, left 30 seconds.

Gait: independent without an assistive device; slightly shorter stance time on the right.

Step-down test (6-inch step): dynamic knee valgus on the right.

LEFS: 52/80 (evaluation 38/80).

Therapeutic exercise, 25 minutes: stationary bike 8 minutes, quad sets, straight leg raises, mini squats 0–45°, step-ups on a 6-inch step.

Neuromuscular re-education, 10 minutes: single-leg stance on foam, lateral step-downs with mirror feedback.

Cold pack to the right knee, 10 minutes, after exercise.

Tolerated treatment well; no increase in pain after the session.

Assessment

Right knee pain (M25.561) and quadriceps weakness (M62.81) after partial medial meniscectomy, progressing as expected. Flexion up 20° and LEFS up 14 points since evaluation, more than the 9-point minimal clinically important difference.

Quadriceps weakness and dynamic valgus on step-down still limit stairs and return to sport.

Short-term goal 1 (full knee extension): met. Short-term goal 2 (stairs step-over-step without a rail): progressing. Long-term goal (return to tennis drills by week 12): on track.

Skilled physical therapy remains needed to progress loading and neuromuscular control safely.

Plan

Continue twice a week for three more weeks, per the plan of care.

Next visit: add lateral band walks, progress step-downs from a 6-inch to an 8-inch step, start leg press 0–60°.

Home program updated, with a handout: add lateral step-downs, 3 sets of 10, once a day.

Progress report at visit 10: repeat LEFS, knee AROM and strength.

Why this note works

  • Every measurement is compared with the evaluation, so progress is visible in one note.
  • A standardized outcome measure (LEFS) is used, and the change is read against its minimal clinically important difference.
  • Each intervention is listed with its minutes, which supports timed billing units.
  • The Assessment says what still limits function and why skilled therapy is still needed, the question an insurer's reviewer asks.
  • Each goal is given a status, and the Plan names the next progression and the date of the progress report.

What to include in each section

Subjective

  • Pain now and at its worst (0–10), and what aggravates or eases it
  • Function since the last visit: walking, stairs, work, sleep
  • Home exercise program done, and how often
  • Falls, new symptoms or medication changes
  • Patient's goal

Objective

  • Range of motion (AROM/PROM) in degrees
  • Strength (manual muscle test or dynamometer)
  • Special tests, balance, gait and transfers
  • Outcome measures (LEFS, Oswestry, NDI, DASH…) with the evaluation score
  • Interventions with minutes: therapeutic exercise, manual therapy, neuromuscular re-education, modalities
  • Response to treatment

Assessment

  • Diagnosis or impairments, with ICD-10-CM codes
  • Progress compared with the evaluation
  • Status of each short- and long-term goal
  • Remaining limits on function
  • Why skilled therapy is still needed

Plan

  • Frequency and duration, per the plan of care
  • Progressions for the next visit
  • Home exercise program changes
  • Date of the next progress report or re-evaluation
  • Referrals or communication with the referring provider

Write yours with the free SOAP note template

The template opens with the physical therapy prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

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More SOAP note examples

Questions

What does Medicare expect in a physical therapy daily note?

Medicare's Benefit Policy Manual (Chapter 15) asks for a treatment note at each visit with the date, the interventions given, the total timed minutes and treatment time, and the signature of the therapist. A progress report is needed at least once every 10 treatment days.

How is a daily note different from a progress note in PT?

A daily note records one visit. A progress report reassesses the patient against the goals in the plan of care, with repeated measures, and justifies continuing or changing care.

Should I record minutes for each intervention?

Yes when you bill timed services: the minutes per intervention and the total timed minutes decide how many units can be billed.

Sources

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