A slight change in movement.

That small wince during stretching.

The way patients shift their weight to avoid pain. 

These small details tell the bigger story of what's really going on in physical therapy.

Miss any of these subtle signs, and you might be delaying your patients’ recovery. Or worse, sending them down a painful, winding path to nowhere.

That’s why clinicians need physical therapy SOAP notes. 

These notes help you capture everything in black and white. Connect the dots from the problem to the solution, and track your patients’ progress over time. 

In this guide, I’ll break down everything about physical therapy SOAP notes. And you’ll find a free template to document each session effortlessly.

What is a physical therapy SOAP note?

SOAP notes aren’t just forms — they’re how you track healing in motion.

A physical therapy SOAP note documents the therapy process in a structured format. It covers all essential details of patient care in four sections:

• Subjective: This includes the patient’s description of their symptoms and concerns. It also captures the changes in physical health since the last visit.
• Objective: This highlights measurable findings like strength testing, functional outcome, and ROM measurements.
• Assessment: This part shares the clinicians’ diagnoses of the patient’s condition. It mentions their progress and prognosis. 
• Plan: This is where clinicians document the ideal treatment and next steps to improve the patient’s physical health.

🔖 Learn more: How to Write SOAP Notes [+ Free SOAP Note Templates] 

While SOAP notes are a popular documentation format, PT soap notes focus specifically on patients’ physical health. Think details like movement patterns and functional abilities. 

Let's take a closer look at these differences.

What makes PT SOAP notes different?

Physical therapy documentation has a few crucial differences from other clinical SOAP notes. 

For starters, PT notes have more detailed objective measurements. A physical therapist evaluates your physical health through quantifiable assessments like the range of motion, strength scores, and standardized functional tests. 

Besides, these notes have a greater emphasis on functionality. Clinicians add objective insights to capture how physical impairments are affecting a patient’s daily routine or quality of life. 

While discussing the treatment plan, PT SOAP notes focus on manual therapy techniques and home programs. Unlike standard clinical notes, physical therapy documentation includes detailed instructions for at-home exercises.

Plus, they share information for regular reassessments to track incremental changes.

The many benefits of using SOAP notes in physical therapy

It’s a busy day. You’re swamped with back-to-back appointments. 

Patient #6 walks in—familiar face, but your mind is racing with questions.

“What was he here for before? What exercises did I tell him? What are his progress markers?”

Then, you find his SOAP notes on your desk. Just like that, the fog lifts and everything comes back to you. That’s just one way PT SOAP notes can make life easier. 

Let’s see how these notes can help you beyond mere paperwork.

Tell the complete story for every patient

Physical therapy SOAP notes present a detailed narrative from injury to recovery. 

Clinicians document every concern and improvement—a shoulder rotation movement, better symmetry while walking, and progress in functional tasks. 

So, when the patient returns after six months with the same pain, you already have a baseline to plan tests and treatment. This can significantly improve patient care outcomes.

Dr. Sean Ormond, a dual board-certified doctor in Anesthesiology and Interventional Pain Management, emphasizes how SOAP notes can effectively track improvements in pain—a critical aspect of physical therapy.

“Pain management is complex because pain itself is so personal. Good SOAP notes help capture that complexity. They let you document a patient’s experience in a way that makes it easier to find patterns, track changes, and communicate with other providers. Plus, they meet legal and insurance requirements while leaving a clear record for future care.”

Present your clinical decisions with rationale

Whether it’s insurance companies or a patient’s family, people likely want to understand (and question) your reasoning behind a treatment plan. That’s when SOAP notes come in clutch. 

You can meticulously document findings from test results, your diagnosis, and decision-making process. This will answer all questions, and build patients’ trust in your clinical expertise. More importantly, it can lead to more approved reimbursement claims. 

Create continuity between transitions 

PT SOAP notes are particularly helpful for patients working with multiple healthcare providers. 

When each clinician prepares detailed charts, nothing gets lost in translation. And the patient receives the right treatment at every touchpoint.

This is also important when dealing with chronic or recurring conditions. If a patient revisits you with an injury flare-up, you don’t have to start charting from scratch. Pick up where you left off the last time.

💡Pro tip: Explain how you’re using an ambient scribe for documentation. Maintain transparency to make patients feel more comfortable and involved in the session.Track every small and big win 

Progress can sometimes feel invisible in physical therapy. But even the slightest improvement counts—and that’s why you need PT SOAP notes. 

These notes capture and remember every bit of improvement, no matter how small or big. This helps in shifting gears in your present treatment strategy and planning for the future. 

Physical therapy SOAP note template (and how it works)

Check out our physical therapy SOAP note template to capture every detail in your sessions. 

Now, let’s contextualize this template with a fictional example. 

Jamie, a 45-year-old construction worker, has been visiting you about a lower back injury. It’s his third physical therapy session. Here’s the SOAP note created for Jamie’s third visit. 

Our field-tested tips to create physical therapy SOAP notes

Okay, you’re ready to use our template and write SOAP notes like never before. 

But before you get started, here are a few actionable best practices to make the documentation process a breeze. 

Keep compliance in mind 

Compliance sits at the heart of physical therapy documentation.

Your notes can be scrutinized in an audit. And they’re equally important for claiming reimbursement.

Clinicians have to meet specific documentation requirements for private insurers and medicare. And it's as overwhelming as it gets. 

That’s why experts recommend preparing PT notes by:

• Connecting impairments to functional limitations
• Adding measurable, objective data to back your decisions
• Including clear progress markers toward established goals
• Using consistent terminology in line with payer requirements

More importantly, be specific. Document the duration and frequency of each session. Add specific insights about the interventions you perform, and explain why. 

Write comprehensive notes without note bloat

Physical therapy notes should be thorough, but not bulky. 

Focus on the most relevant progress indicators instead of covering every single change in a patient’s conditions. And you have to present objective, quantifiable measures rather than relying on subjective descriptions. 

Dr. Ormond shares how you can make the Objective section of your notes truly helpful:

“Combine what the patient shared and what you observed to make a diagnosis, something like chronic low back pain from degenerative disc disease. And if there are multiple problems, note which ones are most urgent or impactful. You have to also consider the bigger picture. Think about psychological, social, or lifestyle factors that might affect their pain.”

Our physical therapy SOAP note template is purpose-built to add more structure to your charting efforts. 

This template will help you build consistency in your notes without missing any details or going overboard with redundant information.

Balance patient interaction with note-taking

Ask any physical therapist about their biggest daily challenge, and you'll hear the same thing: paying attention to patients while making notes. 

Dividing your attention between these equally important tasks can inevitably lead to errors. 

Instead, you should try integrating documentation within your treatment flow. And that’s exactly what Freed can do for you. 

Just hit “Start,” and Freed will record your entire interaction with a patient. Once you’re done, the AI medical scribe will generate detailed and accurate SOAP notes covering all essential insights from the session. Edit it, add to your EHR, and you’re done! 

Put differently: You can create a more natural rhythm in your session, paying complete attention to your patients without the awkward pauses to type some notes.

And, more importantly, you can say goodbye forever to end-of-day documentation. No more pile up charts, no more pajama time.

💡Pro tip: Explain how you’re using an ambient scribe for documentation. Maintain transparency to make patients feel more comfortable and involved in the session.

Use standardized outcome measures for progress mapping

Include proven outcome measures in your SOAP notes to track progress. 

Good outcome measures are important because they:

• Show why you’re recommending a treatment
• Track changes in physical health over time 
• Support your clinical decision-making 
• Help secure insurance payment 

Use measures like the Oswestry Index for back pain, Lower Extremity Functional Scale for leg issues, or QuickDASH for arm problems. 

You can perform these measures in a few minutes and collect solid evidence to back up your treatment plan. As a result, it’s easier to turn any improvement into objective data points and show progress. 

Build documentation as a communication tool

Physical therapy SOAP notes help you communicate with:

• Your future self when the patient returns 
• Other healthcare providers treating the patient
• Insurance companies making payment decisions 
• Legal entities if the care procedure is in question

While your first instinct might be to talk only in clinical jargon, you have to think about the many stakeholders involved in the process. 

Write in clear, simple language to discuss the patient’s concerns and present your diagnosis. Explain your reasoning without adding too many technical terms. And make sure this part confidently communicates your rationale behind every decision.

Free yourself from documentation burden with Freed

It’s almost impossible to make notes in a physical therapy session. You have to be present in the moment and pay attention to your patients. 

What does that leave you with? A pile of paperwork at the end of the day. 

We built Freed for one reason: so you never have to see that pile again.

Freed’s AI medical scribe listens to your patient conversations and turns them into structured SOAP notes in minutes. The tool organizes all the information into different sections and follows your clinical guidelines for maximum accuracy. 

So, you don’t have to pace back and forth from your desk to scribble notes. Give patients your full attention with the best care. And when the day’s done, you’re not stuck finishing notes — you’re out the door, brain clear, body rested, and finally feeling like yourself again.

This is the new normal of thousands of physical therapists. Want to be one of them? Try Freed today.