How to Write Physical Therapy SOAP Notes [+ Free Template]

Updated on: October 5, 2025

Every physical therapist knows that documentation is more than just a compliance requirement — it’s the bridge that connects assessment, treatment, and patient progress. Among the many documentation styles used in healthcare, SOAP notes remain the gold standard for clear, structured, and evidence-based recordkeeping.

If you’ve ever struggled with inconsistent documentation, missing details, or time-consuming charting, this guide is for you. Here, we’ll show you how to write Physical Therapy SOAP Notes efficiently, provide a free SOAP template and sample, and explore how DocScrib AI can make your entire documentation process faster, smarter, and fully EHR-ready.

What Are Physical Therapy SOAP Notes?

SOAP stands for Subjective, Objective, Assessment, and Plan — a standardized method for healthcare professionals to record patient encounters. In physical therapy, SOAP notes are essential for tracking treatment progress, coordinating with multidisciplinary teams, and ensuring compliance with insurance and clinical standards.

Let’s break down the meaning of SOAP in a physical therapy context:

Why SOAP Notes Matter in Physical Therapy

Physical therapy depends heavily on measurable progress and consistent follow-ups. SOAP notes help you:

• Ensure accurate and structured communication between PTs, physicians, and insurance providers

• Track patient progress objectively and show clinical improvement

• Maintain compliance with documentation and audit standards

• Provide proof of medical necessity for reimbursement

• Save time and avoid repetitive note-writing with digital templates or AI assistance

In short, SOAP notes are the lifeline of continuity of care in physical therapy.

How to Write Physical Therapy SOAP Notes (Step-by-Step)

1. Subjective (S): The Patient’s Story

Capture what the patient tells you about their symptoms, pain, or progress since the last session. This section sets the tone for the visit and identifies key focus areas.

Tips for Writing the Subjective Section:

• Use the patient’s own words where possible.

• Include pain level (0–10 scale).

• Note any changes in daily activities or functional goals.

• Record feedback about home exercises or previous sessions.

Example:

“Patient reports improved knee stability during walking; pain reduced to 3/10. Difficulty persists while climbing stairs.”

2. Objective (O): Clinical Measurements & Observations

Here, you record what you observe and measure during the session. This includes all quantitative findings such as:

• Range of Motion (ROM)

• Strength testing results

• Balance assessments

• Gait analysis

• Posture or swelling changes

• Special test outcomes

Example:

“Knee flexion: 130° (previously 115°). Quadriceps strength improved to 4+/5. No tenderness over patellar tendon.”

3. Assessment (A): Professional Interpretation

This is where you synthesize subjective and objective data into a clinical summary. It’s your professional judgment about the patient’s progress and current condition.

Example:

“Patient demonstrates moderate improvement in ROM and strength. Residual pain indicates ongoing inflammation. Treatment plan effective—continue progression.”

Tips for Better Assessments:

• State progress clearly (e.g., improved, stable, regressed).

• Relate progress to initial goals.

• Mention barriers to recovery if present (e.g., poor adherence, pain flare-ups).

4. Plan (P): What’s Next

Outline the treatment steps for the next sessions, home exercise modifications, or changes in therapy frequency.

Example:

“Continue strengthening and proprioceptive exercises. Add resistance band training. Reassess ROM next session. Educate on knee joint protection techniques.”

Include:

• Frequency and duration of treatment

• Short-term and long-term goals

• Home exercise plans

• Referrals or diagnostics (if required)

Free Physical Therapy SOAP Note Template

Here’s a ready-to-use SOAP Note Template for physical therapists. You can copy this into your EHR, print it, or integrate it into DocScrib AI for automatic population.

PHYSICAL THERAPY SOAP NOTE TEMPLATE

Patient Name: ___________________________
Date: ___________________
Therapist: ___________________
Session #: ___________________

S – Subjective:

• Patient’s comments, symptoms, pain rating:

O – Objective:

• ROM, strength, tests, observations:

A – Assessment:

• Clinical summary, progress, interpretation:

P – Plan:

• Next treatment steps, goals, home exercises:

Therapist Signature: _____________________

Sample Physical Therapy SOAP Note Example

Below is a filled example for a post-operative knee rehabilitation case.

Patient: John Taylor
Date: October 5, 2025
Therapist: Dr. Rina Shah, DPT
Session #: 6

S – Subjective:

“Patient reports mild soreness after exercises, but no pain during daily activities. Feels stronger and more stable.”

O – Objective:

• Knee flexion: 135° (was 120°)

• Quadriceps strength: 4+/5

• No swelling or redness

• Able to ascend stairs without handrail support

A – Assessment:

• Good progress in strength and stability.

• Range of motion near full; endurance improving.

• Continue strengthening and balance work to prevent reinjury.

P – Plan:

• Continue 2x/week PT sessions for 3 more weeks.

• Add resistance bands and single-leg balance exercises.

• Re-evaluate for discharge readiness at session #9.

Common Mistakes in Physical Therapy SOAP Notes

Avoiding these common pitfalls can dramatically improve your documentation quality:

How DocScrib AI Simplifies Physical Therapy Documentation

DocScrib AI transforms how clinicians document SOAP notes. Instead of typing or dictating manually, you simply speak naturally during or after a session, and DocScrib automatically creates structured SOAP notes ready for review.

With DocScrib, your SOAP notes are ready in minutes — accurate, structured, and personalized for each patient.

📅 Book a Free Demo Here to see how DocScrib automates Physical Therapy SOAP Notes.

Final Thoughts

Writing Physical Therapy SOAP Notes doesn’t have to be repetitive or overwhelming. With a structured approach — and tools like DocScrib AI — you can turn every session into a clean, data-driven, and insurance-ready record.

A consistent documentation process leads to better patient outcomes, fewer denials, and more efficient workflows.

🚀 Book Your Demo Today
and see how DocScrib can cut your documentation time in half while improving accuracy and compliance.