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 physical therapy soap note example can be used for occupational therapy daily notes as well.
SOAP Note Example: Physical Therapy
The basic outline of a therapy daily note should follow the SOAP format: Subjective, Objective, Assessment, and Plan. Below you’ll find multiple physical therapy soap note example statements for each section of a SOAP note.
Subjective Examples:
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.
Objective Examples
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.
120º flexion of right knee, 0º extension of right knee.
Listing out therapeutic exercise, manual therapy, and neuromuscular re-education may be included in the objective section of your documentation system. If there’s a blank text box for documentation for you to type out all of the activities you performed during the therapy session, you might remark on a couple observations and then include a paragraph as noted below:
Partial Squats: 3×10, Romberg 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.
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.
The therapy assessment section of a SOAP note is the section where you need to highlight why your skill was needed that day. It doesn’t need to be paragraphs long, but avoid repetitive assessment phrases. Use the documentation templates for strategies for typing better assessments in less time.
Plan Examples
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.
Occupational and Physical Therapy SOAP Note Template
Use this therapy note template to guide your daily note documentation.
Subjective
Pain level today?
Functional ability / limitations
Areas of improvement or continued difficulty
Patient quotes on how they’re feeling
Objective
Exercises / Techniques performed
Any measurements taken?
Strength or Balance Tests Performed
Special Tests
Assessment
Therapist’s insights on performance and progress towards goals
Want to Save 30 Minutes on Documentation Every Day?
The therapy documentation templates give you 60 assessment examples for some of the most common exercises performed in therapy.
These templates can save you 30 minutes a day by providing new and detailed assessment phrases that clearly articulate your intention as a skilled therapist.
Download the Therapy Notes Template
Both physical therapists and occupational therapists can save time with the sample therapy note templates. The evaluation template saves the average therapist about an hour a week, which more than pays for the entire therapy note template bundle.
Tim Fraticelli DPT, MBA, CFP®
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.
