PHYSICAL THERAPY SOAP NOTE

Patient name / identifier: [ ]
Consultation date and time: [ ]
Clinician: [ ]
Visit type / body region and side: [ ]

S - SUBJECTIVE
Symptoms, onset and behavior: [ ]
Pain score and context (if used): [ ]
Functional limitations and patient goals: [ ]
Relevant history and screening answers: [ ]
Consent to recording (if applicable): [ ]

O - OBJECTIVE
Examination findings, with region and side: [ ]
Measurements and outcome scores, with units: [ ]
Tests performed and their results: [ ]
Change from previous findings, if established today: [ ]

A - ASSESSMENT
Clinician's interpretation / working diagnosis: [ ]
Supporting findings and contributing factors: [ ]
Progress / response to treatment, if assessed: [ ]

P - PLAN
Treatment provided and response: [ ]
Education and agreed actions: [ ]
Home exercises, with sets, repetitions and frequency: [ ]
Review interval and what to reassess: [ ]
Referral / communication with other providers: [ ]

Reviewed by clinician / date: [ ]