SOAP notes for physiotherapy: structure and examples

You probably learned SOAP notes at university and then spent your first year in practice working out what a real note needs. The textbook version is thorough and slow. The rushed version, written in the car between visits, is quick and sometimes useless to the next person who reads it. A good note sits between the two: short enough to write while the visit is fresh, complete enough that a colleague, a funder or a lawyer can follow your reasoning.

This guide covers what goes in each section, a worked example from a home visit, the mistakes that cause the most trouble, and how to template notes so the structure does some of the work for you.

What goes in each section

S: Subjective. What the patient or their carer tells you: symptoms, function since the last visit, pain on whatever scale you use consistently, adherence to the home program, falls or near misses, new medications or medical events, and their goals in their own words. Quote them where it matters. “I can get to the letterbox now but not back without stopping” tells the next clinician more than “mobility improving”.

O: Objective. What you measured or observed: range of motion, strength, outcome measures, gait, transfers, balance tests and vital signs where relevant. On a home visit the environment is clinical information in its own right: stairs, rugs, lighting, and where the chair sits relative to the toilet.

A: Assessment. Your clinical reasoning. How today's findings compare with last time, progress against goals, what you think is driving the problem, and any red flags you considered and ruled out. This is the section that justifies what you did and why the patient still needs you, and it is the one most often skipped.

P: Plan. What happens next: changes to the home program, education given, referrals or reports to send, when you will see the patient again, and what you will reassess. Many physiotherapy templates add a separate treatment section before the plan, which keeps what you did apart from what you will do next. Either layout works if the whole practice uses it consistently.

A worked example: a home visit after a hip replacement

Here is a hypothetical follow-up note from a home visit, written the way it would read in a well-kept record. The patient and all the findings are illustrative.

Subjective. Reports walking indoors with a four-wheeled walker without help, and to the letterbox with one rest. Pain 3/10 walking, 1/10 at rest. Doing home exercises once a day, not twice as prescribed: “I forget the afternoon ones.” No falls. Goal: walk to the corner shop with her daughter by next month.

Objective. Sit to stand from a dining chair without using arms. Timed Up and Go with walker 18 seconds, down from 23 at the last visit. Right hip abduction weaker than left. Gait: shortened right step, walker pushed too far ahead. Home: loose rug in the hallway, step at the bathroom door.

Assessment. Progressing as expected. Transfers improved; walking tolerance limited by hip abductor weakness and walker technique. Falls risk still raised by the rug and the bathroom step. Adherence is the main barrier to faster progress.

Treatment. Walker height adjusted and gait retrained with cues. Hip abduction and sit-to-stand exercises progressed. Rug moved with the patient's consent; bathroom step discussed.

Plan. Home program simplified to one session a day plus a walking target, with a phone alarm as a prompt. Review in one week: repeat Timed Up and Go. Suggest OT home assessment for the bathroom, to raise with the GP in the next report.

Common mistakes

• A plan with no reasoning. “Continue program” with no assessment tells a funder nothing about why the patient still needs treatment.
• Unmeasured progress. “Strength improving” cannot be compared next time. A number, a named test or a functional marker can.
• Copying last week's note forward. It saves a minute and produces a record that says the same thing for six weeks, including the parts that changed.
• Writing it hours later. Detail fades by evening. Notes written at the visit or straight after are more accurate.
• Private abbreviations. If a colleague or a funder cannot read it, it is not doing its job.
• Leaving out consent and risk. Record that the patient consented to treatment and any risk you identified, especially in someone's home.
• Editing a finished note. Once a note is complete, add an amendment rather than changing what was written. The record should show what was known, and when.

Your record-keeping obligations come from the Physiotherapy Board of Australia's code of conduct, privacy law and your state or territory's health records rules, including how long records must be kept. Confirm the detail with Ahpra and the relevant state regulator.

Templates that do the structure for you

A template is not a form where every box must be filled. It is a reminder of what you would want to see if you read the note cold. Useful physiotherapy templates usually include:

• An initial assessment with history, red flag screening, baseline measures and goals
• A standard follow-up, SOAP or SOAP with a treatment section, for routine visits
• A review template that reassesses against goals, ready for funder and GP reports
• A discharge template that summarises the episode and what the patient should do next

Keep them short. A template with forty prompts gets ignored; one with eight gets used.

How AspireOS helps with notes

In AspireOS, progress notes use templates (SOAP, initial, review, discharge and your own), keep a version history, and can be completed and locked, so a later change adds a version rather than overwriting what was written. You can type, or dictate into each note field where your browser supports speech recognition.

AspireAi helps with the writing, not the thinking. Dictate or paste what happened in your own words, or type something as brief as “pt well, usual strengthening, review 2/52”, and the AI note sorts it under your practice's note headings as a draft. You read it, change what needs changing and save it; nothing enters the record until you do. AspireAi does not diagnose or choose treatments, and it can polish a note into professional wording without changing its meaning, keeping your original. Say “let's do my notes” and it walks you through every visit still waiting for one. See how notes fit into AspireOS and the full feature list.

You can start free and try a note template and the AI note on a test patient before you use them with a real one.