SOAP splits a clinical note into Subjective (what the patient reports), Objective (what you observe and measure), Assessment (your clinical reasoning) and Plan (what happens next). It is the default structure for physiotherapy and most musculoskeletal work.
This template gives you the four headings with prompts under each, based on the fields a physiotherapy note in Atlacare uses. Delete the prompts that do not apply; a short note that answers each heading beats a long one that pads them.
The UK standards it rests on
HCPC Standards of conduct, performance and ethics
Registrants must keep full, clear and accurate records for everyone they care for, completed promptly.
CSP record keeping guidance
The Chartered Society of Physiotherapy's guidance on what physiotherapy records should contain, including consent, clinical reasoning and the plan.
Osteopathic Practice Standards (General Osteopathic Council) and The Code (General Chiropractic Council)
The equivalent record-keeping expectations for osteopaths and chiropractors.
UK GDPR Article 9
Clinical notes are special category health data. Patients can request a copy, so write every note as if the patient will read it.
Must include
Date, time and clinician
Every entry must be attributable and in sequence.
Subjective: presenting complaint, pain and change since last visit
The patient's account, including a pain score, gives the baseline you will compare against.
Red flag screening, at least at initial assessment
Recording that you asked, and the answers, is what protects the patient and you.
Objective: findings with numbers where you have them
Range of movement, strength grades and named special tests can be compared next time. "Reduced" cannot.
Assessment: your clinical impression and reasoning
The section most often left thin, and the one that shows why you chose the treatment.
Treatment given and consent
What you did, and that the patient agreed to it, especially for new techniques.
Plan: next steps, home programme and review
Lets you or a colleague pick up exactly where the last session ended.
Optional
Body chart
Marks pain, tenderness, numbness or referred pain faster and more precisely than prose.
Outcome measure score
A validated measure at set points shows progress in a way the patient and an insurer can both understand.
Chaperone record
Needed whenever one was offered, present or declined.
Goals
Restating the patient's functional goal keeps each session tied to it.
The template
Replace anything in [square brackets]. Print it, save it as a PDF from the print dialog, or copy the text into your own document.
Home exercise programme: [Given / updated / not given]: [Details]
Advice: [Load management, activity modification]
Next appointment: [Date or interval]. Review point: [Date or session number]
Sign-off
[Clinician name], [Profession], registration number [Number]
Use it in Atlacare
SOAP is the default note structure for physiotherapy in Atlacare, and the editor adds profession-specific fields such as range of movement, muscle strength, special tests and treatment techniques, alongside a pain score and a body chart. Each saved edit keeps the previous version, and a note can be locked so it can no longer be changed.
Atlacare