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Templates, Clinical notes, Physiotherapy

Physiotherapy SOAP note template

A physiotherapy SOAP note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01SOAP note

TemplatePhysiotherapy

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Physiotherapy SOAP note

1Subjective

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.
  • Mechanism of injury, onset and aggravating and easing factors.
  • Function lost, and the patient's goals for treatment.
  • Relevant medical history and red flag screening.
  • Current medicines and allergies.

2Objective

  • Observation, range of movement, strength and special tests, with the values recorded.
  • Neurological examination where indicated.

3Assessment

  • The clinical impression, and the structures likely involved.
  • Outcome measure scores at baseline.

4Plan

  • Treatment given and the home exercise programme agreed.
  • Number of sessions planned and the goals for each stage.
  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01SOAP note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Physiotherapy SOAP note

1Subjective

  • Right knee pain for one month since returning to running.00:30
  • Worse on stairs, especially descending. Eases with rest. Goal is to return to 10 km runs.01:50

2Objective

  • Full range of movement. Pain on single leg squat. Tender at the inferior patellar pole.05:10

3Assessment

  • Likely patellar tendinopathy related to a rapid increase in load.06:30

4Plan

  • Load management advised. Home exercise programme started. Six sessions planned.07:20
  • Advised to report swelling or locking.08:00

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a physiotherapy SOAP note?

Subjective, Objective, Assessment and Plan. Each section on this page lists what belongs in it, written for physiotherapy.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

Come back to the note, written and ready to sign.

See the wai scribe write a physiotherapy SOAP note on your own structure, in a 15 minute video call.