Physical Therapy Soap Note Template

Use the Physical Therapy Soap Note Template to record patients' subjective problems, document objective data, provide fair assessments and plan treatments.

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Physical Therapy Soap Note Template

Subjective (S)

Objective (O)

Assessment (A)

Plan (P)

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Physical Therapy Soap Note Template

Use the Physical Therapy Soap Note Template to record patients' subjective problems, document objective data, provide fair assessments and plan treatments.

1. What is the patient's description of the problem, including details about symptoms, pain levels, and how the condition affects daily activities?

2. What is the patient's relevant medical history related to the current condition?

3. What are the patient’s goals and concerns regarding therapy, such as pain relief or increased mobility, and do they have any specific concerns?

4. How does the patient perceive their progress since the last visit, including what has or hasn't improved?

1. What are the results of the physical examination, including range of motion, muscle strength, pain response, swelling, and any other physical observations?

2. What are the results of any diagnostic tests performed, such as X-rays or MRIs?

3. How does the patient perform specific exercises and respond to treatment during the session?

4. What are the vital signs, including heart rate, blood pressure, and respiratory rate if relevant?

1. What is the diagnosis based on the analysis of the subjective and objective data?

2. What is the problem list, including current issues that need addressing, such as pain or decreased range of motion?

3. How is the patient progressing toward their therapeutic goals?

1. What is the treatment plan, including specific therapies or exercises to be administered, their frequency, and duration?

2. What patient education is provided regarding their condition and how do they manage it at home?

3. What are the goals for the next session, and how will they help in tracking progress?

4. When is the next appointment scheduled, and are there any referrals to other healthcare providers?