Physiotherapy SOAP note template

A free physiotherapy SOAP note template that you fill in on screen. There is a box for each heading (subjective, objective, assessment, plan) and a few short prompts under each one. When you are done, print the note or copy it as plain text into your clinic's record system. This page does not store or send anything you type.

Visit Date Time Patient reference

S: subjective

The main concern, in the patient's own words. Put exact phrases in quotation marks.
Symptoms: onset, location, duration, character, what eases and aggravates them, spread, pattern over the day, severity.
Function and activity level, including work and the activities that matter to the patient.
Relevant medical and surgical history, medications and allergies, and answers to screening questions about symptoms not yet mentioned.
The patient's goals. On a follow-up: the response since the last visit and how much of the home program was done.

O: objective

What you observed, tested and measured, stated in measurable terms, with the method so the next measurement can be compared.
Vital signs where relevant, range of motion, strength, special tests, balance, gait and outcome measures.
Signs, not symptoms: what the patient reports belongs in S, what you find belongs in O.
Treatment given today, each intervention with its dose (sets, repetitions, load, time) and any equipment provided.
Communication with colleagues, family or carers.

A: assessment

Your clinical reasoning: what S and O mean when read together.
The problems in order of importance, with impairments linked to what the patient cannot do.
Your working diagnosis, and other possibilities, including less likely ones that could cause harm if missed.
Progress toward the stated goals, and anything that may change how often or how hard you treat.
Response to treatment, including any adverse reaction.

P: plan

Interventions for the next visit, with their objective, what would make you progress them, and precautions.
The home exercise program with its dose, and any education or advice given.
Goals in measurable terms, how often and for how long you will see the patient, and the discharge plan.
Further tests, and referrals or messages to other clinicians.

Clinician name and designation

What you type stays in this page on your device. This page does not save it or send it anywhere, and it is gone when you close or reload the page. Spell check is off in these boxes because some browser spell checkers send text to their own servers.

Preview

Start typing in the form to see your note here.

How to use this SOAP note template

Choose the type of visit and check the date. Add the time if your clinic records it.
For the patient, use the reference your clinic system uses, such as a clinic ID. Keep full names and other identifying details for the clinic's own record.
Work down the four sections. The prompts are only reminders, so you do not need to answer each one. Leave out what does not apply to this visit.
Add your full name and designation at the bottom.
Press Print the note, or Copy as text and paste it into your record system. The printout shows only the note, without the prompts or the rest of this page.

Our guide on how to write SOAP notes in physiotherapy explains what goes in each part and the mistakes that weaken a note. It also has a longer worked example, for a knee patient.

Worked example: a made-up follow-up note

This example is invented. Everything in it, the patient included, is made up to show how a finished note reads. It does not describe a real person, and the doses show how to write a plan, not what to prescribe.

Visit: Follow-up. Patient: Made-up example, not a real patient.

S (subjective)

Made-up patient, 29, right ankle sprain (rolled the foot inward) playing football 3 weeks ago. Second visit, 1 week after the first.
"I can walk to work now, but I don't trust it on the stairs at the station."
Pain 2/10 walking, 4/10 by the end of the day, 0/10 at rest (5/10 walking at visit 1).
Swelling at the outer ankle: less in the morning, more by evening.
Home program done on 6 of 7 days. Band exercises now feel easy. Balance practice done 3 times.
No new injury. No numbness or tingling in the foot. No calf pain or calf swelling.
Goal: back to weekly 5-a-side football.

O (objective)

Walks without a limp on level ground. Stairs: step over step going up, uses the rail coming down.
Mild swelling around the outer ankle bone, less than at visit 1 (visual check). No tenderness over the ankle or foot bones. Right calf soft and not tender.
Knee to wall test (weight-bearing lunge), heel down, big toe to wall measured with a tape: right 7 cm, left 11 cm.
Single leg stance, eyes open, firm floor: right 15 s before touching down, left 30 s (test stopped at 30 s).
Single leg heel raises to fatigue, full height: right 12 with ankle pain 2/10, left 25.
Treatment today: band exercises checked, form correct. Calf raises on both legs 3 sets of 12, pain 2/10 during, settled within a minute. Single leg stance at the kitchen counter practiced with the patient. Advice on building up walking and on stairs.

A (assessment)

Working diagnosis: right lateral ankle sprain, improving as expected since visit 1. Walking pain down from 5/10 to 2/10, and band exercises are now easy.
Main problems, in order: balance on the right leg (15 s against 30 s on the left), calf endurance (12 heel raises against 25), and ankle bending (dorsiflexion) 4 cm short of the left side.
These explain the lack of confidence on the station stairs.
Calf raises caused no more than 2/10 pain, and it settled quickly, so the program can move on to strength and balance.
Other causes that would need different care considered and not suspected: fracture (no bone tenderness), Achilles tendon tear (single leg heel raise possible) and blood clot (no calf pain or swelling, calf soft and not tender). No warning signs reported or found today.

P (plan)

Home program updated and sent to the patient's phone: calf raises on both legs, 3 sets of 12, daily. Calf stretch, 3 holds of 30 s each leg, daily. Single leg stance near a counter, 8 knee lifts on each leg, building each hold up to 20 s, daily. Band exercises stopped.
Next visit in 1 week. Recheck single leg stance, heel raise count and knee to wall.
Progress balance to eyes closed, then to a cushion, once right leg stance is close to the left. No running or football yet.
Short term goals, within 2 weeks: walk down the station stairs without the rail, and stand 30 s on the right leg. Plan a graded return to football at a later visit.
Told to stop and message the clinic if the swelling increases or the ankle gives way. Warning signs that need same-day medical help explained, including new calf pain or swelling, and told to call emergency services if they also become short of breath or have chest pain. Ankle sprain page sent.

Press Fill in the made-up example to load it into the form and see how it prints. The patient reference then reads "Made-up example, not a real patient", so a printout cannot pass for a real record. Each exercise in the plan has its own page: calf raises, calf stretch, single leg stance. The warning signs the plan mentions are on the ankle sprain page.

Where the prompts come from

The subjective prompts follow the StatPearls chapter on SOAP notes by Podder and colleagues: the chief concern, the history of the present problem using the OLDCARTS mnemonic, past history including medications and allergies, and a review of systems for symptoms the patient did not mention. Physiopedia adds the patient's exact words in quotation marks. It also asks for the patient's goals and their response to earlier treatment.

The same chapter separates symptoms from signs. The patient's report of pain goes in S, and tenderness you find when you press goes in O. Physiopedia asks for objective findings in measurable terms, because that helps you compare at the next reassessment.

Podder and colleagues describe the assessment as the synthesis of the subjective and objective findings, with problems listed in order of importance and a differential diagnosis that includes less likely conditions that could cause harm if missed. Physiopedia calls it the therapist's professional opinion, and adds progress toward the goals.

The visit note elements come from the American Physical Therapy Association (APTA) documentation guidelines. Every visit note should include the patient's self-report, the specific interventions with frequency, intensity and duration, changes in status, the response to treatment including adverse reactions, and factors that change the plan, adherence among them. It should also record communication with others and the plan for the next visit, with objectives, progression parameters and precautions. APTA's own example of an intervention with its dose is "Knee extension, three sets, ten repetitions, 10# weight".

SOAP is one format among several. Physiopedia calls it "only one of many possible formats", and the APTA guidelines list what a note contains without naming a format. If your clinic, insurer or regulator uses its own template, follow that.

Record keeping points from the professional bodies

These points are what the two bodies say. The rules that apply to you depend on where you work and who you work for.

The Chartered Society of Physiotherapy (CSP) says records are legal documents that can be called upon in a variety of situations. APTA calls clinical documentation a professional responsibility and a legal requirement.
APTA: documentation is required for every visit, and every entry is dated and authenticated with the provider's full name and designation.
CSP: a good record lets an independent reader understand the conversations, the information exchanged, the extent of the examination, the treatment given and the clinical reasoning.
CSP: its Quality Assurance Standards say notes should be written immediately after the contact or before the end of that working day. The CSP accepts this is not always practical.
CSP: use short forms only if there is an agreed local list that everyone writing in or reading the record can see.
Corrections: APTA says to draw a single line through the error with your initials and the date, or use an electronic method that shows the change without deleting the original. The CSP says amendments are dated, timed and signed, with the original entry still clearly visible.

Privacy: nothing is stored or sent

This page does not save what you type, in the browser or anywhere else, and it does not send it to PocketPhysio or anyone else. Reload the page and the note is gone, so print it or copy it first.

A SOAP note is a patient record, so treat every copy of it that way, printed or on screen.

Do not type or paste names, dates of birth, phone numbers or other details that identify a patient on a shared or public computer.
Copy as text puts the note on your device's clipboard, where other apps on that device can read it. If clipboard history or clipboard sharing between devices is turned on, a copy can stay there, or reach your other devices, after you copy something else.
Browser extensions that are allowed to read the pages you visit can read what you type here too.
The official record belongs in your clinic's record system. Follow your clinic's policies and the data protection and health records law where you work.
The CSP advises that electronic devices used for records are password protected.

Sources

Podder V, Lew V, Ghassemzadeh S. SOAP Notes. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 28 August 2023. NBK482263
Physiopedia. SOAP Notes. physio-pedia.com/SOAP_Notes
American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G03-05-16-41, last updated 19 May 2014. APTA guidelines (PDF)
American Physical Therapy Association. Physical Therapy Documentation of Patient and Client Management. apta.org/your-practice/documentation
Chartered Society of Physiotherapy. Record-keeping guidance. Last reviewed 19 August 2025. CSP record-keeping guidance

This template is a writing aid for clinicians. It is not a record system, and it does not replace your clinic's records or the rules of your regulator.