How to write SOAP notes in physiotherapy, with a worked example

SOAP stands for Subjective, Objective, Assessment and Plan. In a physiotherapy SOAP note, Subjective is what the patient tells you, Objective is what you measure and see, Assessment is your reasoning about what it means, and Plan is what happens next, home program included. Write it so a colleague who has never met the patient could run the next session from your note alone. If you want the headings in front of you while you write, our physiotherapy SOAP note template prints out with a prompt under each one.

The format comes from the problem-oriented medical record that Lawrence Weed set out in a 1968 paper, and it is now used widely across healthcare. Podder and colleagues, in their StatPearls chapter on SOAP notes, describe it as a structure that supports clinical reasoning and communication between clinicians. That second part matters most in a busy clinic. Your note is how the next physio, the referring doctor, or you in three weeks' time find out what actually happened.

What goes in each part of a SOAP note

S: subjective

This is what the patient reports. Pain goes here: where it is, how bad on a 0 to 10 scale, what brings it on, what eases it, and how it behaves over 24 hours. So does function in their own terms: stairs, sleep, work, the walk to the bus. On a follow-up, add how they responded to the last session and how much of the home program they managed.

Use their words when the words carry information. "My knee gives way on the stairs" tells the reader more than "reports instability". Record your red flag screening here as well: that you asked, and what the patient said. A blank space in the note reads as a question you never asked.

O: objective

This is what you measured and observed: range of motion, strength, special tests, functional tests, gait, swelling, and what you did in the session. Put a number on anything that has a number, and write the method so the next measurement can be compared. "Knee flexion 110 degrees, supine, goniometer" can be repeated next week. "Flexion improved" cannot.

Many physios also record the treatment given in this section. The American Physical Therapy Association (APTA) documentation guidelines ask that every visit note name the specific interventions provided, with the dose where relevant: how often, how hard, how long. Their own example is "knee extension, three sets, ten repetitions" with the weight used.

A: assessment

This section shows whether you actually thought about the patient. Read S and O together. Is the patient moving toward the goals you set, and what explains the change or the lack of it? What is the main problem now?

The APTA guidelines list the patient's response to treatment, including any adverse reaction, as part of every visit note, and this is the natural place for it. Keep it short if you like. Two sentences of real reasoning are worth more than a paragraph that repeats the objective findings in different words.

P: plan

What happens next, written specifically enough that someone else could do it. That means the interventions for the next visit, what would make you progress or regress them, any precautions, the home program with dosage, how often you will see the patient, and any referral or message to the doctor. The APTA suggests the plan for coming visits should cover the interventions with their objectives, progression parameters, and precautions where needed.

First visit notes and follow-up notes

An initial assessment note is long, and it should be. The APTA guidelines describe the examination as the history, a systems review and your tests and measures. Your evaluation and diagnosis come next, then a plan of care. That plan includes goals stated in measurable terms, the interventions you intend to use, how often and for how long, and the expected discharge plan.

A follow-up note is shorter because it only has to record what changed. Did the patient improve against the goals from visit 1? What did you do today, how did they respond, and what will you do next time? APTA states that documentation is required for every visit, so the quick session where "nothing much happened" still gets a note.

The test every note should pass

The Chartered Society of Physiotherapy (CSP) puts it well in its record-keeping guidance. A good record lets an independent reader understand what conversations took place, what information was exchanged, how far the examination went, what treatment was given, and what clinical reasoning decisions were made. The CSP also reminds physios that records are legal documents that can be called on in a variety of situations.

SOAP is a layout, not a rule in itself. The APTA guidelines describe what a note should contain without naming any one format, and SOAP is just one common way to organize that content so nothing gets missed. Your employer, insurer or regulator may have its own requirements. Follow those first.

Common mistakes in physiotherapy SOAP notes

1. A vague subjective. "Pt feeling better" tells the next physio nothing. Better in what way, compared with when, and by how much?
2. Measurements nobody can repeat. A range of motion figure without the position or method cannot be compared next week, even by you.
3. An assessment that only repeats the objective findings. If you deleted the A section, would anything be lost? If not, it is not doing its job.
4. "Continue as per plan." Which plan, at what dose, and what would change it? Write the actual exercises and numbers.
5. Private abbreviations. The CSP advises using short forms only if there is an agreed list, developed locally, that everyone writing in the record can access. The shorthand you learned as a student may not be the one your colleague reads.
6. Writing notes at the end of the week. The CSP guidance quotes its quality standards: notes should be written immediately after the contact or before the end of that working day. It accepts this is not always possible, but the aim is clear. Friday afternoon memory of a Monday patient is not a record.
7. Leaving out the home program. The APTA lists adherence to the patient's instructions as one of the factors that can change how often or how hard you treat. If the home program and how much of it got done are missing from the note, so is half the picture.
8. Deleting mistakes. The APTA guidelines say to correct a paper entry with a single line through the error, with your initials and the date, and to use an electronic method that shows a change was made without deleting the original. Do not overwrite.

Worked example: a follow-up SOAP note

The patient below is invented. The details are made up to show the format and do not describe a real person, and the dosages show how to write a plan rather than what to prescribe. Set your own from your assessment and adjust as the patient responds.

Ms. K, 58, left knee osteoarthritis (see our knee osteoarthritis program for background), third visit, one week after visit 2.

S (subjective)

• "Walked to the market and back without stopping. First time in months."
• Pain going down stairs 4/10, was 6/10 at the first visit. Going up now 2/10.
• Morning stiffness about 15 minutes.
• Home exercises done on 5 of 7 days. Skipped the step-ups twice because the knee ached that evening. The ache settled by the next morning both times.
• No new symptoms. Denies fever, calf pain, or a hot, swollen knee.

O (objective)

• Left knee flexion 115 degrees, supine, goniometer (105 degrees at visit 1). Extension lacks 5 degrees, unchanged.
• 30-second chair stand: 10 (8 at visit 1).
• No visible swelling, knee not warm to touch.
• Stairs: step over step going up. Coming down uses the rail and pauses on the left leg.
• Treatment today: quad sets and straight leg raise checked, form correct. Mini squat to a shallow depth, 3 sets of 10, no increase in pain. Step-up on a 10 cm step, 2 sets of 8, pain 3/10 during, back to baseline within 2 minutes. Advice given on pacing walking on busy days.

A (assessment)

• Progressing toward the visit 1 goals. Flexion is up 10 degrees and walking tolerance is better. Chair stand is up by 2, a small change, so recheck it before reading much into it.
• Evening ache after step-ups settles by morning, with no swelling or warmth, so the exercise stays in. The daily home dose looks a little high for now.
• Main limit now is control coming down stairs on the left leg.

P (plan)

• Home program updated and sent to the patient's phone: quad sets 2 sets of 10, hold 5 s, daily. Straight leg raise 2 sets of 10, daily. Mini squat 3 sets of 10, daily. Step-up on 10 cm step, 2 sets of 8, reduced from daily to alternate days.
• Next visit in 1 week. Progress step height to 15 cm only if the alternate-day step-ups no longer cause an evening ache and the knee stays free of swelling. Start step-down practice with rail.
• Recheck flexion and chair stand at visit 5.
• Goal from visit 1 unchanged: walk to the market and back with pain no higher than 2/10.
• Precaution: patient told to stop the step-ups and message the clinic if the knee becomes hot or swollen, or if the ache is still there the next morning. If a hot, swollen knee comes with fever or feeling unwell, see a doctor the same day.
• Signed with full name and designation. Date and time recorded.

Read it as the colleague covering next week would. The trend is clear from S and O. The A section explains why step-ups dropped to alternate days, and the P section says what to try next and what would make them stop. That is what the format is for.

Where the home program fits

The P section is where many notes go thin, and it is also where the patient's week actually happens. Write the exercises and the dosage in the note, then give the patient exactly the same thing.

With PocketPhysio you build the program in the app and send it by link, SMS or email, through Pocket Physio Care, our patient app, or on WhatsApp. Each exercise has a video and a voice guide, so the patient does at home what you wrote in the plan. When they come back, you can see what you gave them last time and progress it, which makes the subjective question "how did the exercises go?" much easier to ask properly. For how to get a better answer to that question, read why patients don't do their home exercises.

The short version

A good physiotherapy SOAP note records what the patient said, what you measured, what you think it means, and what happens next, in enough detail that someone else could pick up the case tomorrow. Put numbers on things and write the reasoning, not just the findings. The real home program belongs in the plan, and the note should be written the same day.

References

1. Chartered Society of Physiotherapy. Record-keeping guidance. Last reviewed 19 August 2025. https://www.csp.org.uk/professional-clinical/professional-guidance/record-keeping-guidance
2. American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G03-05-16-41, last updated 19 May 2014. https://www.apta.org/siteassets/pdfs/policies/guidelines-documentation-patient-client-management.pdf
3. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. In: StatPearls. Treasure Island (FL): StatPearls Publishing; last updated 28 August 2023. https://www.ncbi.nlm.nih.gov/books/NBK482263/
4. Weed LL. Medical records that guide and teach. New England Journal of Medicine. 1968;278(11):593-600. doi:10.1056/NEJM196803142781105

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.