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.
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.
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.
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.
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.
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.
- 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 is the focus?
- What will be the focus of 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 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.