SOAP Notes for Exercise Physiology: EP-Specific Format and What iCare Expects
By The Kitt Team
SOAP notes for exercise physiology use the same four-section structure as any allied health note. The content is different. A physiotherapy template will leave gaps in your documentation because EP notes carry cardiopulmonary data, functional capacity measures, and exercise test results in the Objective, exercise-capacity reasoning (not diagnosis) in the Assessment, and reproducible exercise dosage in the Plan. For the generic structure, see SOAP notes explained. For the physio version, see SOAP notes for physiotherapy. This post covers the EP-specific format, iCare expectations for NSW Workcover cases, and a worked example.
Subjective: what the EP client reports
Referral source and reason first, including insurer and claim number for Workcover clients. Document symptoms in functional terms: what the symptom stops the client doing, not just a pain rating.
Cover exercise history, medical history affecting exercise response (cardiovascular conditions, diabetes, respiratory conditions, relevant medications), and work demands for Workcover clients (job title, physical requirements, current work status, modifications in place). Client goals belong here too, in the client’s own words.
Objective: the measures exercise physiologists use
This is where EP documentation diverges most from other allied health notes. Record each measure with units and date.
Cardiopulmonary: resting HR (bpm), BP (mmHg), RPE on Borg 6-20 or modified 0-10 (specify which), SpO2, submaximal test results. Example: “6MWT: 480m (predicted 560m), HR peak 132bpm, RPE 14/20, SpO2 >95%.”
Anthropometric: height, weight, BMI, waist circumference, body composition if assessed.
Functional capacity: 30-second chair stand (reps), grip strength (kg, both hands), timed up and go (seconds). For Workcover clients: lift capacity (kg), carry distance (metres), standing and sitting tolerance (minutes), work-task simulation results.
Outcome measures (score and date): PSFS 0-10 for patient-nominated activities, NPRS pain 0-10, EQ-5D, DASS-21, K10. For diabetes clients, blood glucose (mmol/L) pre- and post-exercise.
Assessment: exercise capacity and clinical reasoning
Assessment for an EP is reasoning about exercise capacity, not diagnosis. Document capacity relative to normative data or functional demands, risk stratification (ESSA pre-exercise screening, ACSM risk category), contraindications and precautions, and barriers to adherence.
For Workcover clients, state the gap plainly: “Client currently lifts 10kg; role requires 20kg repetitive lifting; 8-week graded programme planned.” That is programming rationale, not work-capacity certification (which sits with the treating doctor). Include prognosis, timeframe, and red or yellow flags.
Plan: exercise prescription with dosage
“Exercises given” is not a plan. Dosage and progression are what make it reproducible and defensible.
Cardiorespiratory: mode, intensity (target HR zone, RPE range, or % HRmax), duration, frequency, and progression criteria.
Resistance: named exercises, sets, reps, load (kg or % 1RM), rest periods, and a progression rule (e.g. “increase 2.5kg when 3x12 completed at RPE below 7”).
Flexibility/mobility: exercises, hold duration, frequency.
Functional/work-specific: task-specific drills with quantified progression (e.g. progressive lifting from 10kg to 20kg, standing tolerance from 30 to 60 minutes).
Education: specific messages, not “educated re: condition.” Home programme: full dosage, not just exercise names. Review: timeframe and reassessment criteria. For Workcover clients, link each goal to RTW with a SMART target.
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What iCare expects from EP documentation
SIRA is the regulator; iCare is the insurer funding most NSW worker claims. The AHTR (Allied Health Treatment Request) is the form you use for treatment approvals. For the full distinction, see iCare and SIRA documentation.
AHTR goals must be SMART and tied to function and return-to-work. “Improve fitness” does not pass. “Increase 6MWT from 480m to 540m within 6 weeks, supporting return to a warehouse role requiring sustained walking” does. Objective functional measures with baseline-and-current data are required each review period. Document in work-relevant terms, not general comments about progress.
A full EP SOAP note example
Generic illustrative case only. No real client or clinic.
Presentation: 34-year-old male warehouse worker. Workcover, lower back injury from manual handling, 6 weeks post-onset, referred for RTW conditioning.
S: Client reports lower back pain NPRS 4/10 at rest, 7/10 with lifting. Pain limits sustained bending and lifting above 10kg. Role requires 20kg repetitive lifts and 6-hour standing shifts. Currently on modified (sedentary) duties. Exercise history: gym 2x/week pre-injury, nil since injury. Goal: full return to warehouse duties without pain flare.
O: Resting HR 74bpm, BP 128/82mmHg. 6MWT: 480m (predicted 560m for age/sex), HR peak 132bpm, RPE 14/20, SpO2 >95%. 30-second chair stand: 14 reps. Grip strength: 42kg right, 40kg left. Lift capacity: 10kg floor-to-waist (pain limited). Standing tolerance: 30 minutes. PSFS: lifting 3/10, prolonged standing 4/10. NPRS: 4/10 rest, 7/10 lifting. Lumbar flexion 45 degrees, extension 15 degrees.
A: Exercise capacity below age-predicted norms (6MWT 480m versus predicted 560m). Current lift capacity (10kg) is 50% of job requirement (20kg). Standing tolerance (30 minutes) is well below shift demand (6 hours). ESSA screening: low-moderate risk for supervised exercise. Contributing factors: deconditioning, pain-related movement avoidance, reduced lumbar mobility. Yellow flag: mild fear-avoidance with lifting. Red flags: nil. 8-week graded RTW conditioning programme indicated.
P: Cardiorespiratory: treadmill walking at 65-75% HRmax (approx 120-138bpm), RPE 12-14/20, 20 minutes, 3 sessions/week. Progress to 30 minutes when RPE stays below 13 for two consecutive sessions. Resistance: goblet squat 3x12 at 8kg, Romanian deadlift 3x10 at 12kg, seated cable row 3x12 at 10kg, rest 90 seconds. Progress load by 2.5kg when 3x12 completed at RPE below 7 for two sessions. Functional/work-specific: progressive floor-to-waist lifting from 10kg to 20kg over 8 weeks using correct manual handling technique; standing tolerance building from 30 to 60 minutes per session. Education: discussed pain-movement relationship and graded exposure rationale. Home programme: walking 20 minutes 3x/week, hip flexor stretch 3x30 seconds daily. SMART RTW goal: lift 20kg floor-to-waist for 10 repetitions per hour within 8 weeks, supporting full return to warehouse duties. Review: 4 weeks.
Frequently Asked Questions
What outcome measures should an exercise physiologist use in SOAP notes?
The core set is PSFS (0-10 for patient-nominated activities), NPRS (pain 0-10), EQ-5D, DASS-21, and K10. For Workcover clients, add objective functional capacity measures: 6MWT, grip strength in kg, 30-second chair stand, and lift capacity. Record each with the score and date so baseline-versus-current comparisons are clear for iCare reporting.
How do you document exercise prescription dosage in a SOAP note?
State mode, intensity (HR zone, RPE range, or % HRmax), duration, frequency, and progression criteria for each modality. For resistance training, name the exercises with sets, reps, and load in kg. Without this detail, another clinician cannot reproduce the session, and iCare cannot verify the programme is progressing toward RTW goals.
What does iCare expect in EP progress documentation?
SMART goals in the AHTR tied to function and return-to-work, objective functional measures with baseline-and-current data each review period, and clear evidence the programme is moving toward the stated RTW target with specific numbers, not general comments about progress.
Key Takeaways
- EP SOAP notes use the standard four-section structure; the content in each section is EP-specific.
- Objective: record cardiopulmonary data, functional capacity measures, and outcome scores with dates.
- Assessment: clinical reasoning about exercise capacity and the RTW gap, not diagnosis.
- Plan: dosage and progression criteria across cardiorespiratory, resistance, flexibility, and functional/work-specific modalities.
- iCare AHTR goals must be SMART and tied to return-to-work function with measurable functional targets.
- “Exercises given” is an activity record. Dosage and progression are what make it a clinical plan.