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Soap Note Example

The physical therapy note summarizes a session with a patient seeking treatment. It includes subjective reports from the patient, objective measurements of vital signs at rest and following activity, details of interventions provided in the session, home exercises prescribed, an assessment of the patient's status and progress, defined goals for treatment, and a plan for the next session. The therapist observed improvements in the patient's balance, strength, and coordination during interventions and noted goals were still being met or were in progress.

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Josh Kuntz
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232 views3 pages

Soap Note Example

The physical therapy note summarizes a session with a patient seeking treatment. It includes subjective reports from the patient, objective measurements of vital signs at rest and following activity, details of interventions provided in the session, home exercises prescribed, an assessment of the patient's status and progress, defined goals for treatment, and a plan for the next session. The therapist observed improvements in the patient's balance, strength, and coordination during interventions and noted goals were still being met or were in progress.

Uploaded by

Josh Kuntz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Question to ask yourself: would someone else be able to treat my patient based on this note?

Physical Therapy Daily Note (session _ of _ )

Patient Name:
Age:
Date:
Time:
Physical Therapy Dx:
Medical Dx:
Chief Complaint:

SUBJECTIVE:
Pt reports…

OBJECTIVE:
Resting Vitals: ​(note location and patient position)
HR:
BP:
RR:

(repeat)​ Vitals following activity: ​pt tolerance to activity (CVP systems)


- Note what activity, patient BORG/RPE
- Look at d ​ ose response​ to see if CV system response to activity is improving!!!
HR:
BP:
RR:

Interventions: ​pt position, pt response, assist levels, ​skilled part (PT)​, feedback, cueing,
KR/KP, sets and reps, progression, observation
● Neuro re-education
● Therex
● Theract
● Manual Therapy
● Etc.

HEP: ​date of HEP prescription,​ ​include teach back of HEP (pt demonstrates), amount of
feedback (tapering off)

ASSESSMENT:
- Pt progression/improvement
- Levels of assistance
- PT observation of pt during session
- PT assessment during manual therapy
- Pt response to exercise (and tolerance)
- Tie to chief complaint and goals!!!
- PICO question (hypothesis that will help pt achieve their goals)
- CVP response to activity
- Motor learning terms (stage of learning, principles of neuroplasticity)
- Pt body structure and function impairments, activity limitations, participation restrictions
- And WHY are they having these problems

Ex: Pt BP has decreased since last visits without change in diet, exercise, or medications. BP
variability may be psychogenic in nature d/t pt subjective statements. Pt is continuing to have
difficulty with balancing on unstable surfaces due to diminished sensation and proprioception in
the distal aspect of both LEs, decreased ankle and hip strategies. BPPV tx last session was
successful, pt states she has no residual symptoms of dizziness/vertigo. As pt participates in
balance exercises pt demonstrates increased confidence in ability to maintain balance and a
lower level of assistance from SPT. Pt demo’s improved activation of TrA without global muscle
contraction. Pt also has decreased strength in scapular stabilizers and bilat RTC, forward head,
thoracic hyperkyphosis and tightness in pec muscles, causing primary impingement, especially
the left shoulder.

Patient specific SMART Goals:


- MCID, MDC, SEM, etc.
- Use outcome measures
- Achieve on DATE and revised to further improvement!
- Tie to chief complaint and functional measures

Goal 1 (date set):


(met/not met/in progress)

Goal 2 (date set):


(met/not met/in progress)

Goal 3 (date set):


(met/not met/in progress)

Goal 4 (date set):


(met/not met/in progress)
PLAN:
- Plan for next session and reasoning
- Progression next session
- What has worked?
- Number of sessions remaining
- HEP details

Ex: Continue progressing static and dynamic balance exercises on stable and unstable surfaces
while also challenging the cognitive and vestibular systems. Progress UE strengthening
exercises for HEP. Incorporate core stabilization/strengthening exercises in POC along with
practice of balance strategies to dec risk of falls. Continue including UE exercises in POC to
address UE weakness/ROM deficits. Pt will receive therapy 1x/week for 8 weeks as tolerated, 4
visits remaining.

Patient consented to evaluation and treatment.

Therapist Signatures and Date

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