How to Write SOAP Notes for Physiotherapy (With Examples)

Most physios are taught what SOAP stands for. Fewer are taught why it matters.

A clinical note is not a record of what you did. It is the evidence that would defend you if a patient complained to the HCPC two years from now. Write it with that in mind.

What each section actually does

S — Subjective

The patient's account, in their words or a close paraphrase. Presenting complaint, how it started, what makes it better or worse, anything relevant from their history.

What belongs here: pain location, onset, mechanism of injury, aggravating and easing factors, relevant past history, the patient's goals for treatment.

What does not belong: your interpretation. If the patient says "my shoulder started hurting when I began the new job," write that. Save your interpretation for the A section.

O — Objective

Measurable findings from your assessment. This is where your clinical credibility lives.

Include: posture and movement observation, range of movement in degrees (not "reduced"), strength grades or manual muscle test scores, special tests and their results, pain score on the NRS (0 to 10, at rest and on movement), palpation findings, neurological screen if relevant.

Standard abbreviations (ROM, NRS, MMT) are fine. Spell out anything a colleague might not recognise.

A — Assessment

The most underdeveloped section in most physio notes. This is not a diagnosis label. It is your clinical reasoning.

A good assessment section answers: What is the most likely diagnosis and why? What is the severity and irritability? What is the prognosis? Has the patient improved, plateaued, or deteriorated since last time? What is limiting progress?

"L shoulder impingement" is not an assessment.

"Presentation consistent with right supraspinatus tendinopathy, moderate irritability. Good movement gains this session. Pacing and load management remain the primary barrier to recovery." That is.

P — Plan

What you will do next, and why. This section should be useful to any colleague who picks up this patient in your absence.

Include: treatment provided today, home exercise programme, number of sessions planned, next appointment date, and what would trigger a reassessment (for example, symptoms not improving after three sessions, or onset of new symptoms).

Example 1: Initial MSK assessment

S: 38-year-old runner presenting with right lateral knee pain over four weeks. Gradual onset, no trauma. Worsens with running beyond 20 minutes and descending stairs. Eases with rest and ice. No previous knee history. Goal: return to marathon training in 12 weeks.

O: No swelling or bruising. Full AROM bilaterally. Ober's test positive right. Pain on palpation at lateral epicondyle and along ITB. Hip abductor strength 4/5 right vs 5/5 left. NRS 0/10 at rest, 5/10 descending stairs.

A: Presentation consistent with right iliotibial band syndrome, low-to-moderate irritability. Hip abductor weakness likely a contributing factor. Good prognosis given acute presentation and patient's fitness baseline.

P: Education on load management and temporary reduction in running volume. HEP: hip abductor strengthening (3 exercises). Review in 2 weeks. If no improvement after 3 sessions, consider referral for imaging.

Example 2: Follow-up note

S: 3rd session. Patient reports 30% reduction in pain. Running 15 minutes before onset last week. No new symptoms.

O: Ober's test still positive but less restricted. Hip abductor 4+/5 right. NRS 2/10 descending stairs (was 5/10 at initial assessment).

A: Progressing as expected. Gradual return to load underway. No flags for onward referral at this stage.

P: HEP progressed to eccentric loading. Running increased to 20 minutes every other day. Next session in 2 weeks.

Five mistakes to stop making

Writing the A section as a diagnosis label. "Lateral hip pain" tells the HCPC nothing about your clinical reasoning.

Recording outcome scores without naming the tool. Write "NRS 4/10" not "pain 4." If you use a validated questionnaire, name it and record the score in full.

Vague plan entries. "Continue exercises" tells a colleague nothing. Name the exercises, the load, the sets.

Skipping the patient's own account of progress in follow-up notes. The S section of a follow-up note should record what the patient reports since the last session, not just repeat the original presenting complaint.

Copy-pasting the O section from the previous note. If you do not update the measurements, the note is not evidence that you re-assessed. It is evidence that you did not.

How long should a SOAP note be?

A solid initial assessment note runs 150 to 250 words. A follow-up note runs 80 to 150 words. If yours are consistently shorter, something is missing. If they are consistently longer, you are probably including information that belongs in a separate document (such as the intake form or a treatment plan).

The test: would a physio colleague who has never met this patient know exactly where you are clinically and what to do next? If yes, the note is long enough.