How do I write a physiotherapy SOAP note with an AI scribe?

The Hanah team · 12 September 2026

The short answer: an AI scribe writes your SOAP note from what it hears, so the note can only be as good as what you say out loud. Narrate your objective findings as you test, with the figure, the unit and the side. Let the scribe sort the consult into Subjective, Objective, Assessment and Plan. Then check the draft against your own memory of the session before you sign it.

Below is what each section should hold, what to say in the room, a worked example, and a checklist for reviewing the draft. We build Hanah for physiotherapists, so where we describe how a scribe behaves we use Hanah's physio SOAP template as the example. The habits apply to any scribe.

What goes in each section of a physio SOAP note?

Subjective is the patient's account: how the problem started, where and how much it hurts (with a score such as NRS where you use one), what makes it worse or better, what they can't do, what they want to get back to, and relevant history and screening answers.
Objective is what you found: observation, active and passive range of motion in degrees, strength as a grade or a dynamometer reading, special tests with side and result, neurological screen, palpation, and any outcome measure scores.
Assessment is your interpretation: the likely source of symptoms, contributing factors, and how today compares with last time.
Plan is what you did and what happens next: treatment given, education, the home program with its dose, the review interval, and any referral or report.

Hanah's physio SOAP template follows the same shape. Its instructions ask for the Subjective as one short paragraph, in the patient's own words where that helps; Objective findings one per line with figures and units, leaving out anything not assessed; the Assessment in one or two sentences, leading with the symptom and then the likely condition; and the Plan as short, action-first points.

What does the scribe need to hear you say?

A scribe can't see your goniometer. If a finding isn't said, it isn't in the transcript, and it won't be in the note. Five habits make most of the difference:

Say the number, the unit and the side. "Left knee flexion 115 degrees" is recordable. "That's better" isn't.
Say the test and the result. "Lachman's negative on the left, McMurray's painful but no click."
Say the comparison. "Up from 95 last week." Hanah uses the last version of the same note for this patient as a guide to structure and to what you tracked, and it's instructed not to carry old values forward: every figure in today's note has to be supported by today's session.
Say the dose. "Three sets of twelve, once a day." That's what the patient's home program will carry.
Say the red flags you cleared. "No night pain, no pins and needles, bladder and bowel normal." A negative screen you don't voice can't be recorded.

Before any of this, ask the patient's consent to record and note their answer. Ahpra's guidance says an AI scribe that records the consult will generally need informed consent, ideally noted in the record (Ahpra).

What does a finished note look like?

This is an illustrative example. "Sam" is a fictional patient, and we wrote the note to show the shape of a good one; it isn't output from a real consult.

Sam is 42, plays social tennis, and has had six weeks of right shoulder pain. Here's a fragment of what the physio said while examining:

"Right flexion's about 150, left is full, 175. Painful arc from 80 to 120. External rotation 70 on the right, 85 left. Resisted external rotation, that's a 4 out of 5 on the right and it hurts. Hawkins-Kennedy positive on the right, Neer's positive. Lag sign's negative, drop arm negative."

And the initial assessment, in the Standard register:

Subjective

Six-week history of gradual-onset right lateral shoulder pain after increasing tennis to four sessions a week. NRS 6/10 reaching overhead and serving, 2/10 at rest. Wakes when lying on the right side. No trauma, no neck pain, no pins and needles. Goal: serve pain-free before the club season in eight weeks.

Objective

R shoulder flexion 150° (L 175°)
Painful arc 80–120° abduction, R
R ER 70° (L 85°)
Resisted ER 4/5 R, painful; 5/5 L
Hawkins-Kennedy positive R; Neer's positive R
ER lag sign negative; drop arm test negative
Cervical screen clear
PSFS: serving 3/10, reaching overhead 5/10

Assessment

Right lateral shoulder pain with a painful arc, positive impingement tests and painful resisted external rotation, consistent with rotator cuff related shoulder pain following a rapid increase in tennis load.

Plan

Education on load: serving paused for two weeks, groundstrokes continue if pain stays at or under 3/10
Home program: banded shoulder external rotation 3 × 12 daily; shoulder wall slide 2 × 10 daily
Sleeping position advice
Review in one week: re-test resisted ER and painful arc, progress load

Notice what isn't there. No internal rotation figure, because it wasn't measured. No palpation findings, because none were said. A good scribe leaves the gap for you to fill rather than filling it for you.

How is a progress note different?

It's shorter, and it's mostly about change. Hanah's physio progress note starts in clinical shorthand and the initial assessment in the Standard register, and you can switch either. Sam's review a week later might read:

S: R shoulder NRS 4/10 overhead (was 6). Doing HEP ~5 days/wk. Groundstrokes OK.

O: Flex 165° (was 150). Painful arc 100–120°. Resisted ER 4+/5, pain-free.

A: Improving; tolerating load.

P: Progress ER to 3 × 15, add prone Y. Serving paused one more week. RV 1/52.

Those "was" figures appear only because the physio said them aloud during the review.

How do I check the draft before I sign it?

The record is yours, whoever typed it. Ahpra's AI guidance says a practitioner using an AI scribe is responsible for checking the accuracy and relevance of the records it creates. The records expectations don't change either. In Australia, the Code of conduct summary asks for records that are accurate, up to date, factual and legible, made at the time or as soon as possible afterwards (Ahpra). In the UK, HCPC standard 10 asks for full, clear and accurate records, completed promptly (HCPC). In New Zealand, the Physiotherapy Board's health records standard expects records another physiotherapist could continue care from, with red flags, cautions and contraindications recorded (Physiotherapy Board of New Zealand).

A two-minute check that covers most errors:

Sides. Every finding has the right side. Laterality is the easiest thing to get wrong and the most important to get right.
Numbers. Every figure matches what you measured, with its unit.
Tests. Only tests you performed, with results the right way round.
Gaps. Anything you found but didn't say out loud. Add it now.
Extras. Anything you didn't say or do. Delete it.
Dose. The home program in the Plan matches what you told the patient.
Consent and red flags. Both noted.

In Hanah, nothing becomes part of the record until you've reviewed and signed it. If you want to know how often a scribe gets things wrong before you trust it, ask for measured error rates. Ours are in our accuracy and hallucination report.

Where does the Plan go after the note?

The Plan is also the start of the patient's home program. In Hanah, the same consult drafts a care plan the patient reads on their phone, with an exercise card for each exercise you prescribed, picked from the library at the dose you stated. We cover that, and the reports to GPs that follow a course of treatment, in what a physiotherapist should look for in an AI scribe.

FAQ

Can I use my own headings instead of SOAP? Yes. The records guidance linked above asks for accurate records that another practitioner can follow; it doesn't prescribe SOAP. In Hanah you can change the headings, add sections such as outcome measures, or upload your own Word or PDF template.

Will it write into Cliniko? Hanah works inside Cliniko, Halaxy, Nookal and Zanda in your browser. On Cliniko it can draft against your existing treatment note templates and file the note as a draft that you finalise in Cliniko.

What if the wifi drops mid-consult? Hanah keeps recording to the device and catches up when the connection returns, so the session isn't lost.

What if the consult isn't in English? Hanah detects the spoken language automatically, including switches mid-sentence. The clinical note is written in English.

Does the scribe decide the diagnosis? It drafts an Assessment from the findings in the session, but the clinical judgement and the signature are yours. If the Assessment says more than you concluded, change it before you sign.

If you'd like to see this with your own templates and caseload, see Hanah for physiotherapists.