Different formatting guidelines have been developed to help with writing progress notes, including SOAP and DAP. Depending on your preferences, and the requirements of your practice, you may choose to utilize physical therapy software to help streamline your clinical documentation. Remember, consistency is key!
Physical therapy progress note example
This template is indicative of the type of information that physical therapists should include in a SOAP note. We will break down the different sections and provide you with a brief example of what should be included.
- Subjective (S): Subjective statements from the patient about their feelings and any progression they have noticed since the beginning of treatment.
The patient says that over the past week, the pain in her shoulder has been 4/10. She says she can now move her arm to head-level without experiencing sharp pain in her shoulder. She has been using muscle relaxants.
- Objective (O): This section includes the results of any relevant tests and assessments completed during the session. It would help if you discussed whether the results of these tests are positive or negative.
The patient's PROM for flexion has improved from 90 degrees to 140 degrees. The strength in her available range of motion has been enhanced from 3+/5 to 4+/5.
- Assessment (A): A professional conclusion based on information provided in the subjective and objective sections. Comment on the patient's progression towards their goals and whether you recommend any changes or modifications to the treatment plan.
The patient has achieved their short-term goals as identified in the last session. Long-term goals, including full ROM into shoulder flexion, have not yet been reached. We will target these objectives during the subsequent four sessions.
- Plan (P): The final section of a SOAP note outlines the specific treatment plan and intervention for the patient, including future assessments, referrals, and sessions.
The patient has demonstrated improvements, so that we will continue the current treatment plan. The patient will have a PT session weekly over the next four weeks.
Learning how to write practical progress notes is a critical aspect of providing quality healthcare to your clients. There are different strategies for physical therapists that can assist in producing clinical documentation, including using a SOAP format and online therapy software. Carepatron offers HIPAA-compliant sophisticated, and high-quality services that can help you in the process of writing efficient and effective physical therapy progress notes.
Hopefully, this guideline has given you insight into the different methods and techniques that can be utilized to write accurate progress notes. As long as you keep on top of your documentation and prioritize consistency, clarity, and conciseness, your progress notes will work to both your and your patient's advantage!