SOAP Notes for Physiotherapy: Worked Example and Template

SOAP notes for physiotherapy are built on the same four sections as any other SOAP note, but every entry is filled with musculoskeletal and movement-specific content. Where a general practitioner might write “back pain,” a physiotherapist writes pain location, direction of movement that aggravates it, joint range of motion in degrees, and muscle strength on a 0 to 5 scale. The four letters (Subjective, Objective, Assessment, Plan) stay the same. The content is entirely yours. This guide covers what goes into each section of a physiotherapy SOAP note, walks through one worked example, and offers a copy-ready template. For the generic structure and history of SOAP notes, see SOAP notes explained.

What makes a physiotherapy SOAP note different

A physiotherapy SOAP note uses the same four sections as SOAP notes explained, but the Subjective records what the patient reports about pain and function; the Objective captures joint range of motion in degrees, muscle strength grades, and named orthopaedic tests with their results; the Assessment is your clinical reasoning linking those findings to a working diagnosis in musculoskeletal terms; and the Plan prescribes manual therapy and an exercise programme with specific dosage and progression. Every section reflects the physio-specific content that separates a physiotherapy SOAP note from general clinical documentation.

Subjective: what the physio patient reports

The Subjective section opens with the mechanism of injury: was onset acute (a twist, fall, or impact) or insidious (gradual, no clear trigger). Then record pain location precisely (right shoulder anterior, left lower back midline, right knee medial), its behaviour over 24 hours (morning stiffness that eases with movement, pain worse by end of day), and the movements or postures that aggravate it or bring relief. Note irritability (does pain return quickly if the patient overuses the joint, or is it stable) and severity (how much does it limit the patient’s ability to work, exercise, or manage daily tasks). Functional limitations belong here in the patient’s own language: cannot lift above shoulder height, unable to run more than 2 kilometres, struggling with stairs. Add prior episodes and patient goals (return to sport, pain-free desk work, independent gardening). Patient-reported outcome measures are introduced and administered here, but their scores are recorded in Objective.

Objective: the measures physios actually use

The Objective section holds the measurable findings from your assessment. Range of motion is recorded in degrees for both active ROM (AROM, where the patient moves the joint) and passive ROM (PROM, where you move it), with the affected side compared to the unaffected side and any symptoms noted at end range. For example: R shoulder flexion AROM 140°/170° (L), painful at end range. Manual muscle testing uses the 0 to 5 Oxford and Medical Research Council scale, where 0 means no contraction, 3 means full range of motion against gravity, and 5 means normal strength against full resistance. You might record shoulder abduction 4/5, painful. Special and orthopaedic tests are named with their result (positive or negative); for a right subacromial presentation, you might use Hawkins-Kennedy (positive suggests impingement), the empty-can test or Jobe’s (targets supraspinatus), and the painful arc (pain roughly 70 to 120 degrees of abduction suggests impingement). Outcome measures belong here with their score and date: PSFS (patient-nominated activities, 0 to 10), NPRS (pain, 0 to 10), LEFS (lower-limb function, 0 to 80), or ODI (low back disability, percentage score). Pick the measure that fits your patient’s body region and functional goals.

Assessment: physiotherapy clinical reasoning

The Assessment section is your clinical reasoning. State the working diagnosis or clinical impression in musculoskeletal terms (right subacromial syndrome, acute left lower back strain, functional limitation in knee extension), then link the subjective and objective findings to that impression. Note the stage of the presentation (acute, subacute, chronic) and irritability (how easily symptoms are provoked). Name contributing factors (posture, weakness, movement pattern, activity load, psychosocial), and document the absence of red and yellow flags if they are not present, that absence is as important as their presence. Include a brief prognosis (expected recovery timeline, likelihood of return to function). On a follow-up note, the Assessment records progress against baseline. Assessment is clinical reasoning, not a restatement of the diagnosis label.

Plan: manual therapy, exercise prescription and dosage

The Plan describes treatment delivered in this session and what happens next. Manual therapy is written with specifics: not “mobilised shoulder,” but “glenohumeral joint mobilisation, grade III, 3 sets of 10 oscillations.” The home exercise programme is where the plan becomes reproducible and defensible. And exercises prescribed without dosage aren’t a plan at all: they’re a wish. Write the exercise with set count, repetition count, load or resistance (bodyweight, band colour, dumbbell weight in kilograms), frequency (daily, three times per week), and how it progresses over sessions. Education is part of the plan: specific messages about what to do and why (posture during desk work, sleep position, movement patterns to avoid during symptom aggravation), not “educated re: condition.” Set a review timeframe: when you expect to see the patient again and what you are reassessing at that visit.

A full physiotherapy SOAP note example

S: Right-hand dominant 42-year-old presented with right shoulder pain, onset two weeks ago during overhead lifting at work. Pain is anteromedial and worse with overhead movement and lifting. Night pain disturbs sleep. Pain worsens with work tasks, partially eases with rest. First episode. Goal: return to full work duties without pain. NPRS 7/10 today, PSFS (overhead lifting, sleep quality, reaching into cupboard) initial scores [date].

O: Posture: mild forward head, slight right shoulder elevation. AROM: R shoulder flexion 130°/170° (L), painful at end range; abduction 100°/170° (L), painful; external rotation 45°/70° (L). PROM: similar to AROM, no additional gain. R shoulder abduction 4/5, painful; external rotators 4/5, painful. Special tests: Hawkins-Kennedy test positive (pain with internal rotation at 90° abduction); Jobe’s empty-can test positive (pain with supraspinatus contraction); painful arc present at 80 to 110 degrees abduction. Palpation: tenderness over subacromial space and anterior shoulder. No neural tension signs. Red flags absent.

A: Right subacromial syndrome (rotator cuff-related shoulder pain), acute presentation, moderate irritability. Likely mechanism: cumulative overload during overhead work. Contributing factors: weakness in external rotators, possible postural component with forward head posture. Findings consistent with supraspinatus-dominant involvement. Prognosis: good; typically 4 to 6 weeks with appropriate loading and exercise compliance.

P: Glenohumeral joint mobilisation, grade III, 3 sets of 10 oscillations, one or two sessions per week. Home exercise programme: external rotation in neutral (sidelying, light dumbbell 1 to 2 kilograms, 3 sets of 10, daily); prone horizontal abduction (3 sets of 10, bodyweight, daily, progress to band resistance week 2); scapular setting (3 sets of 15, daily). Postural cue: chin tucks during desk work. Sleep: trial prone or sidelying, avoid supine. Avoid aggravating movements (overhead lifting) until pain settles. Review in one week to reassess ROM, strength, and activity tolerance.

A copy-ready physio SOAP note template

This is a starting skeleton for your own documentation. Adapt it to your patient, your clinic, and your clinical reasoning. It is not a substitute for clinical judgement. This template is the physio SOAP note format you can use and refine:

**S:** [Age, handedness] presented with [location] pain, onset [acute/insidious], [mechanism if known]. Pain behaviour [24-hour pattern: morning stiffness, end-of-day fatigue, night pain, etc.]. Aggravating factors [movements/postures]. Easing factors. Functional limitations [specific tasks: work, sport, ADLs]. Prior episodes [yes/no, frequency]. Patient goals. Outcome measures administered (NPRS, PSFS, etc.) [scores] [date].

**O:** Posture [observations]. AROM/PROM [joint, affected vs unaffected in degrees, symptom at end range]. Manual muscle testing [movement, grade 0 to 5, note if painful]. Special tests [name, result: positive/negative]. Palpation [findings]. Neurological screening [tone, reflexes, signs present/absent]. Outcome measures [PSFS, NPRS, LEFS, ODI, etc., with score and date]. Red flags [absent/present, describe if present].

**A:** Working diagnosis [clinical impression in MSK terms]. Reasoning [link subjective and objective findings]. Stage [acute/subacute/chronic] and irritability. Contributing factors [weakness, posture, movement pattern, load, psychosocial, etc.]. Red/yellow flag status. Prognosis [recovery timeline, likelihood of functional return].

**P:** Manual therapy [technique, grade if applicable, sets and oscillations/reps]. Home exercise programme [exercise, dosage (sets, reps, load, frequency), progression]. Education [specific messages]. Review timeframe [next visit, what will be reassessed].

Frequently Asked Questions

How do you record range of motion in a physiotherapy SOAP note?

Record both AROM (what the patient can move) and PROM (what you can move) in degrees. Always compare the affected side to the unaffected side. Note any symptom at the end of available range. Example: R hip flexion AROM 100°/130° (L), pain at end range shows right hip flexion reaches 100 degrees, the left hip reaches 130 degrees, and there is pain when you test the right side’s end range. This format is clear, concise, and defensible.

What outcome measures should a physiotherapist use?

Choose the measure that matches your patient’s body region and functional goal. PSFS (Patient-Specific Functional Scale, 0 to 10) lets the patient nominate the activities that matter most to them. NPRS (Numeric Pain Rating Scale, 0 to 10) is quick and tracks pain. LEFS (Lower Extremity Functional Scale, 0 to 80) is sensitive to lower-limb function. ODI (Oswestry Disability Index, percentage score) is the benchmark for low back disability. Administer it at baseline and at each review to track progress objectively. For workers compensation episodes, those scores also feed Workcover progress reports.

Can AI write physiotherapy SOAP notes?

Kitt listens to your physiotherapy session and drafts a structured SOAP note from the session for you to review, edit and approve. Notes are ready in under 60 seconds. You remain the author and clinical reasoner: Kitt handles the transcription and structure, you own the reasoning and the final note. Kitt is an AI clinical assistant; it is not a practice management system and does not do billing.

Key Takeaways

• SOAP notes physiotherapy uses the same four sections as any SOAP, but content is musculoskeletal: joint angles in degrees, muscle strength graded 0 to 5, named orthopaedic tests with results, and exercise prescription with dosage and progression.
• Objective findings must be specific: ROM in degrees (affected vs unaffected), MMT graded on the Oxford scale, named tests with outcomes, and outcome-measure scores with dates.
• Assessment is your clinical reasoning: working diagnosis, the link between findings and that impression, stage, irritability, contributing factors, flag status, and prognosis. It is not a restated diagnosis label.
• The Plan is defensible only if it includes dosage: sets, reps, load, frequency, and how the exercise progresses. “Exercises given” is not a plan.
• Outcome measures must fit the body region. PSFS, NPRS, LEFS, and ODI are validated tools that give you objective data on progress.
• Follow-up notes in the Assessment section record progress against your baseline.