SOAP notes for physiotherapists: how to write them, and how PhysioDesk keeps them

A session note is written in two minutes and read for years: by you next week, by a colleague covering your patients, by the patient if they ask for their record, and occasionally by an insurer. The SOAP format (subjective, objective, assessment, plan) is the most widely used way to keep notes short and complete. Here is how to write each part well, with an example, and how PhysioDesk records it.

S: subjective

What the patient tells you since the last session, in their words where it matters:

• how the problem has been: better, worse, the same

• pain now and at its worst, on the same 0 to 10 scale you always use

• how they responded to the last session and to the home exercises

• anything new: a fall, a new symptom, a change in medicines

Example: "Knee better on stairs. Pain 3/10 going down, was 5/10. Did exercises most days. Some stiffness in the morning, settles in 10 minutes."

O: objective

What you measured and observed today:

• range of motion in degrees

• strength, swelling, gait, or a functional test you can repeat

• what you gave: treatments, exercises and their dose

Example: "Knee flexion 115 degrees active (was 105). Swelling reduced. Single leg stand 20 seconds (was 12). Treatment: mobilisation, quads and hip strengthening, stair practice."

A: assessment

Your interpretation. Is the patient progressing as expected? Why or why not? This is the part most often left out, and the part that shows clinical reasoning.

Example: "Improving as expected. Range and balance both up. Morning stiffness consistent with the healing stage, not a concern."

P: plan

What happens next:

• changes to treatment or exercises

• the home programme, with any progression

• when you will see the patient next, and when you will reassess

Example: "Progress step-ups to 15 cm. Add single leg balance on cushion. Review in 3 sessions; reassess range and stairs."

Habits that make notes useful

• Write the note while the patient is still fresh in your mind, ideally before the next one walks in.

• Use numbers wherever you can. "Better" means little next month; "105 to 115 degrees" means a lot.

• Keep each part short. A note is not a letter.

• Record what you advised, not only what you did.

SOAP notes in PhysioDesk

• A note on every session. When you mark a session completed, the note has a field for each part: chief complaint, observation, assessment and plan. A therapist who only has time for one line can write one line; the structure is there when it helps.

• Signed and timed. The note records which therapist signed it, to the second.

• Still editable. A completed session cannot be changed, but its note stays open, so you can add something you remembered later.

• Every edit kept. The change history shows who changed the note and what it said before.

• Templates for the notes you write often. Each therapist can save their own note templates and start the next note from one with a tap, which helps on a busy day of similar sessions.

• Read across the course. On the patient's record every session's note is in date order, so the whole story reads from top to bottom.

Pain scores and range of motion can also be recorded as progress measures, which PhysioDesk charts over time, so the numbers in your notes become a graph your patient can see.

Try it

Complete a session and write a note in the 30-minute demo on the pricing page.