There are 4 main parts to a good therapy daily note. Let’s look at the key components of a physical therapy daily note. The same example can be used for occupational therapy daily notes as well.
SOAP Note Physical Therapy
The basic outline of a therapy daily note should follow the SOAP format: Subjective, Objective, Assessment, and Plan.
“The patient reports difficulty sleeping on his side due to shoulder pain. He presents today with 4/10 pain along the left biceps. Reaching behind his back to tuck in his shirt has become easier over the past week.”
“Today the patient reports increased swelling in her knee. She attributes this to walking more than 20 minutes last night at the grocery store. She is still hesitant to leave the house without her walker.”
The subjective statement includes any insights you have from the patient on their current status or ability to perform certain tasks at home. Making notes of their functional ability or limitations can help to jog your memory the next time you ask questions on how things are going with the patient.
“Posture: right scapula abducted and internally rotated while sitting.”
“Lacks full upward rotation of scapula on active shoulder flexion”
“50% quad contraction noted with terminal knee extension”
“120 degrees flexion of right knee, 0 degrees extension of right knee”
Including therapeutic exercise, manual therapy, and neuromuscular re-education may be included in the objective section of your documentation system.
“Partial Squats: 3×10, Rhomberg stance with perturbations: 3×30 seconds, SLS with hand hold assist: 3×15 seconds, standing hip abduction/extension: 3×10 with yellow band, lateral step up: x15, front step over 10” hurdle x10 at parallel bars, supine SLR 3×10, cold pack x10 in supine to right knee”
For over 60 Assessment examples, take a look at the post: Therapy Documentation Example Templates to Save Time.
“The patient demonstrated improved ability to reach overhead with 2# weight. Further strengthening of the serratus anterior should aid in the precise motion of the GHJ to avoid impingement.”
“Multiple verbal cues were required to remind the patient on proper walker placement and sequencing. Further gait training will be required for safe ambulation per the recommended total knee replacement protocol.”
In many EMRs, the assessment and plan are combined. Regardless of the format, you can use the Plan section (or extend your assessment section) to include the recommended treatments to perform the next visit. This will help you or another therapist progress the patient appropriately.
“Progress with increased resistance bands for standing exercises.”
“Focus on quad strengthening through standing exercises and balance activities”
“Provide patient with updated HEP and red theraband.”
Therapy Daily Note Template
Use this daily note template to guide your daily note documentation.
- Pain level today?
- Functional ability / limitations
- Areas of improvement or continued difficulty
- Patient quotes on how they’re feeling
- Exercises / Techniques performed
- Any measurements taken
- Strength or Balance Tests Performed
- Special Tests
- Therapist’s insights on performance and progress towards goals
- Patient’s response to treatment
- Why should therapy continue?
- What will be the focus
- What is the focus for the next treatment
- Areas to address next visit
- Is a progress note due?
Want to Save 30 Minutes on Documentation Every Day?
The therapy documentation template provides you with 60 assessment examples for some of the most common exercises performed in therapy.