How Do You Write a SOAP Note for Physical Therapy?

How Do You Write a SOAP Note for Physical Therapy?

Most physical therapy notes are in the SOAP format, which stands for Subjective, Objective, Assessment and Plan. While there is no specific policy regarding the amount of detail or length of each entry, the American Physical Therapy Association recommends what type of information should be reported in a SOAP note.

Information that should be recorded includes: the patient's self-report, changes in the patient's status, details about the course of treatment that is given, complications or negative reactions, the equipment used in treatment, factors that change the treatment, progression towards goals, and communication with other care providers, the patient and his family.