Occupational and Physical Therapy Soap Note Example

Soap Note ExampleThe basic outline of a therapy note should follow the SOAP format: Subjective, Objective, Assessment, and Plan.

Both occupational therapy and physical therapy soap notes should have the same basic format whether you are writing an evaluation, a daily note, a progress note or a discharge note.  

Occupational and Physical Therapy SOAP Note

A well crafted therapy soap note will include the following:

Subjective

  • What is the patient’s pain level today?
  • Describe the patient’s functional ability or limitations.
  • Are there examples of improvement or continued difficulty?
  • Include patient quotes on how they’re feeling.

Sample Subjective for a daily note:

The patient presents today with 3/10 knee pain following the total knee replacement 2 weeks ago. He has been performing her HEP daily and notes decreased radiating symptoms in the AM.  He continues to manage his symptoms with ibuprofen daily and reports improved ability to reach to low cabinets in the kitchen. Descending stairs have been very difficult due to LE weakness.

Some people might consider this to be a little long, but it really only took about 30 seconds to write. It provides a very detailed description of how the patient is doing on that day.  A good subjective will clearly identify functional limitations and even improvements for the patient.

Objective

  • Any exercises or therapeutic treatments performed.
  • List out any measurements taken; the data you collect.
  • Performance of strength or balance tests.
  • Special tests and results, including vital signs.

Sample Objective for a daily note:

Vitals before treatment: BP 130/88, HR 72 BPM
Knee Flexion: 105 degrees

Therapeutic Exercise performed:

  • Partial Squats 3×10
  • Standing Hip ABD with yellow theraband: 3×10 reps
  • Standing Hip EXT with yellow theraband: 3×10 reps
  • Hamstring stretch in standing at step: 3×30 sec
  • Step up to 6” surface: x15 reps

Neuromuscular Re-Ed Performed

  • SLS on balance Pad 3×30 seconds
  • Tandem stance with perturbations: 3×30 seconds
  • Grapevine stepping at parallel bars: 2 min
  • Standing rocker board for balance training: 2 min

Assessment

  • Therapist’s insights on performance and progress towards goals.
  • How did the patient respond to treatment?
  • Why should therapy continue? Any deficits noted?
  • What will be the focus of future treatments?

Sample Assessment for a Daily note:

The patient demonstrated improved knee flexion today following therapeutic exercises performed today.  He continues to have difficulty with descending stairs which should improved with further strengthening of the quads as well as increasing his knee ROM.  Single leg stability is limited to 2 seconds, so further treatment should focus on improving balance through dynamic stabilization exercises.

Plan

  • What is the focus for the next treatment?
  • Any specific exercises to include?
  • Is a progress note due?

Sample Plan for a Daily note:

Continue to progress with lower extremity strengthening to promote hip stability and knee flexion ROM.  Consider eccentric strengthening of quads and provide patient with red theraband for HEP

Write Faster SOAP Notestherapy documentation

If you’re a new therapist or if english is not your first language, writing a SOAP note can take a long time. It’s not uncommon to spend an additional 60+ minutes a day writing notes.

Take a look at our therapy documentation templates that provide multiple samples of documentation phrases and examples.

 

Tim Fraticelli, DPT | Physical Therapist

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™ and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your financial health.