Free SOAP Note Generator for Physical Therapy
Generate complete PT SOAP notes from your session keywords. Our AI understands range of motion measurements, manual muscle testing, functional assessments, and rehabilitation documentation conventions.
PT SOAP Notes
SOAP notes are the standard documentation format in physical therapy practice. PT SOAP notes emphasize measurable outcomes, functional progress, and evidence-based interventions. Accurate documentation supports treatment authorization, demonstrates medical necessity, and tracks rehabilitation progress.
Section Guide for Physical Therapists
S - Subjective
Document the patient's self-reported pain levels, functional limitations since last visit, activity tolerance, compliance with home exercise program, and overall perception of progress. Use pain scales (NRS 0-10) for consistency.
O - Objective
Record measurable data: AROM/PROM measurements, manual muscle testing grades (0-5), special tests, gait analysis, functional mobility assessments, balance testing, and treatment interventions performed (manual therapy, therapeutic exercise, modalities, neuromuscular reeducation).
A - Assessment
Provide clinical reasoning about the patient's response to treatment, functional progress or barriers, rehabilitation potential, and justification for continued skilled services. Reference objective data to support your assessment.
P - Plan
Outline treatment modifications, HEP updates, progression criteria, frequency and duration of visits, short-term and long-term goal updates, and discharge planning timeline.
Common PT Assessment Tools
| Tool | Purpose |
|---|---|
| Oswestry (ODI) | Low back pain disability |
| DASH | Upper extremity disability |
| LEFS | Lower extremity function |
| Berg Balance Scale | Balance and fall risk |
| TUG | Timed Up and Go (mobility) |
| 6MWT | Six Minute Walk Test (endurance) |
Physical Therapy SOAP Note Example
S - Subjective
Patient is a 55-year-old female, 6 weeks status post left rotator cuff repair. She reported pain at 4/10 with overhead reaching activities and 2/10 at rest. She stated she has been compliant with her home exercise program and noticed improved ability to reach for items on lower shelves. She denied any new numbness, tingling, or sharp pain.
O - Objective
Left shoulder AROM: flexion 120 degrees (from 95), abduction 100 degrees (from 80), external rotation 30 degrees (from 20). PROM: flexion 140 degrees, abduction 120 degrees. MMT: flexion 3+/5, abduction 3/5, ER 3/5. Negative impingement signs. Manual therapy performed: posterior glenohumeral mobilizations grade III. Therapeutic exercise: TheraBand ER/IR, wall slides, pendulums. Patient demonstrated good form with all exercises.
A - Assessment
Patient is making good progress toward rehabilitation goals. AROM has improved 25 degrees in flexion and 20 degrees in abduction since last visit. Strength is gradually improving and pain with activity is decreasing. Patient is demonstrating good compliance with HEP and is appropriate to progress to Phase 3 of rehabilitation protocol.
P - Plan
Progress to Phase 3 exercises: add light resistance strengthening, scapular stabilization exercises, and proprioceptive training. Update HEP with progressive resistance band exercises. Continue manual therapy for posterior capsule tightness. Treatment 2x/week for 4 weeks. Short-term goal: achieve 140 degrees active flexion within 3 weeks. Long-term goal: return to full overhead function by 12 weeks post-op.
Frequently Asked Questions
How do I document ROM in a PT SOAP note?
Document ROM in the Objective section using specific measurements in degrees. Specify AROM (active) vs PROM (passive), the joint and movement measured, and include comparison to previous measurements when available. Example: "Left shoulder AROM flexion 120 degrees (previously 95 degrees)."
What should I include to support medical necessity?
Document skilled interventions that require PT expertise, objective measurements showing progress or justifying continued care, functional limitations that impact daily activities, and how your treatment plan addresses specific, measurable goals. The Assessment section is where you make the case for continued skilled services.