How to Write SOAP Notes in Physiotherapy (With Examples)
Good clinical documentation is a professional and legal requirement — and a skill that separates competent clinicians from excellent ones. SOAP notes (Subjective, Objective, Assessment, Plan) are the most widely used documentation format in physiotherapy. This guide explains each section, what to include, what to avoid, and provides real examples.
Why SOAP Notes Matter
SOAP notes serve multiple purposes beyond simply recording what happened in a session:
- Continuity of care — Any clinician picking up your notes should be able to understand the patient's presentation and your clinical reasoning without asking you.
- Legal protection — Your notes are a legal document. If a complaint or adverse event occurs, your documentation is your defence.
- Communication — Notes are read by other members of the MDT: doctors, nurses, OTs, and social workers. Clarity and precision matter.
- Clinical reasoning — Writing forces you to organise your thinking. Students who write good notes tend to reason better clinically.
The standard in the NHS is that notes must be contemporaneous (written at the time or as soon as possible after), accurate, and legible.
S — Subjective: What the Patient Tells You
The Subjective section records information from the patient's perspective: their symptoms, history, and concerns.
What to include: - Chief complaint in the patient's own words (use quotation marks) - Location, nature, and severity of symptoms (pain score 0–10) - Onset, duration, and mechanism - Aggravating and easing factors - 24-hour pattern - Relevant past medical history, medications, and investigations - Patient's goals and concerns
Example (MSK): "Patient reports right shoulder pain 6/10 at rest, 8/10 with overhead activity. Onset 3 months ago, insidious, no trauma. Aggravated by reaching overhead and sleeping on right side. Eased by rest and ibuprofen. No red flags identified. Goal: return to swimming training."
What to avoid: - Your interpretation in the Subjective section (save that for Assessment) - Vague phrases like "patient complaining of pain" — be specific - Irrelevant information that does not influence your clinical reasoning
O — Objective: What You Find on Examination
The Objective section records your measurable, observable findings.
What to include: - Observation (posture, muscle wasting, swelling, gait) - Active and passive range of movement (with degrees) - Strength testing (MRC scale or specific tests) - Special test results (name the test and the finding) - Palpation findings (location, nature of tenderness) - Neurological screen if relevant (sensation, reflexes, myotomes) - Outcome measures (NPRS, PSFS, Oxford Knee Score)
Example (MSK): "Observation: mild right deltoid wasting. Active ROM: flexion 140° (L 180°), abduction 120° (L 180°), ER 40° (L 70°). Painful arc 70–110°. Neer's sign positive. Hawkins-Kennedy positive. Empty Can: pain and mild weakness. Palpation: tenderness over greater tuberosity. Neurovascular screen: intact."
What to avoid: - Subjective language ("patient seemed to be in a lot of pain") — use objective measures - Missing laterality (always record which side) - Omitting units (degrees, cm, kg)
A — Assessment: Your Clinical Reasoning
The Assessment section is where you interpret your findings and form a clinical impression. This is the most intellectually demanding part of the note.
What to include: - Working diagnosis or clinical impression - Differential diagnoses considered and why they were included or excluded - Contributing factors (biomechanical, psychosocial, lifestyle) - Prognosis and any flags (yellow, orange, red) - Response to previous treatment (if applicable)
Example: "Presentation consistent with right subacromial impingement syndrome. Rotator cuff tear cannot be excluded given weakness on Empty Can — will monitor response to treatment and refer for imaging if no improvement in 4 weeks. Contributing factors: forward head posture, reduced thoracic mobility, overhead sport demands. No red flags. Yellow flags: mild work-related stress reported."
What to avoid: - Stating a diagnosis without supporting evidence - Ignoring psychosocial factors - Copying the same Assessment section from session to session without updating it
P — Plan: What You Are Going to Do
The Plan section records your treatment plan, patient education, and goals.
What to include: - Treatment provided in this session (techniques, parameters, sets/reps) - Home exercise programme (with specific exercises and dosage) - Patient education provided - Short-term and long-term goals (SMART format) - Next appointment and plan for review - Any referrals or onward communication
Example: "Treatment: soft tissue massage to posterior capsule (5 min), posterior capsule stretch (3 × 30s), scapular stabilisation exercises (3 × 15 reps). HEP: pendulum exercises, external rotation with band (3 × 15 reps daily). Education: activity modification, avoid overhead loading for 2 weeks. Goal: pain-free overhead reach by 6 weeks. Review in 2 weeks. If no improvement, refer for ultrasound."