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.
