SOAP Note Template (Physical Therapy)
Published: 10/22/2025
About this template:
This physical therapy SOAP note template enables efficient documentation of rehabilitation sessions. It includes sections for functional assessments, range of motion measurements, therapeutic exercises, and progress toward goals. The template facilitates clear documentation of treatment interventions, patient education, and home exercise program compliance, making it ideal for outpatient and post-surgical rehabilitation.
Preview template
Subjective: 56-year-old female status post right total knee arthroplasty 4 weeks ago presents for 6th physical therapy session. Reports decreased pain, now 3/10 with activity. Able to ambulate 200 feet with straight cane independently. Continues to have difficulty with stairs, requires railing. Morning stiffness present but improving. Compliance with home exercise program excellent, performing exercises twice daily as instructed. Taking pain medication only at night.
Objective: Ambulates with antalgic gait pattern, minimal weight shift to right. Range of motion: Knee flexion 95 degrees (goal 110), extension -5 degrees (goal 0). Strength: Quadriceps 4-/5, hamstrings 4/5. Girth measurements show continued decrease in swelling (2cm circumference decrease since last visit). Transfers sit to stand with minimal difficulty. Stair negotiation: Ascends with step-to pattern using railing, descends with increased caution.
Assessment and Plan:
- Status post right total knee arthroplasty, progressing toward functional goals
- Treatment today: Therapeutic exercises including passive and active-assisted range of motion, strengthening exercises (leg press, straight leg raises, hamstring curls), gait training emphasizing weight shift and stride length, stair training
- Manual therapy: Soft tissue mobilization to improve patellar mobility
- Modalities: Ice applied post-treatment
Patient Education:
- Advanced home exercise program to include mini squats and step-ups
- Instructed in scar massage techniques to improve tissue mobility
- Reviewed importance of achieving full extension to prevent gait deviations
- Discussed timeline for return to recreational activities (walking for exercise in 2-4 weeks)
Patient demonstrates understanding and proper form with new exercises. Continue physical therapy 2x weekly for 4 more weeks. Progress note sent to referring physician.
