A physical therapy SOAP note, line by line
2026-09-04 · 10 min read
One real-shaped visit written twice — once the way it usually gets written, once the way it survives a review. The clinical content is identical. Only the sentences change.
The note in full
Visit 5 of a certified plan, right-sided low back pain, four weeks post-onset, no red flags.
S
Reports right low back pain 4/10 today, 6/10 at evaluation. Worst on rising from sitting after 30+ minutes at the desk. Completed home programme 5 of 7 days; skipped prone extensions on the two days pain woke her.
O
Lumbar AROM flexion 55° (40° at eval), extension 15° (8°), R side-bend 20°, L 25°. Prone instability test negative today, positive at eval. Therapeutic exercise 23 min: sit-to-stand 3 × 10 with verbal cue for hip hinge; prone extension 2 × 10 with tactile cue to unload the shoulders. Manual therapy 13 min: grade III central PA L4-L5 prone, 3 × 30 s, re-tested flexion after.
A
Flexion up 15° over four visits and the instability test has converted, supporting continued skilled intervention. Cueing still required for hip hinge under fatigue, so the pattern is not yet safe to progress unsupervised.
P
2×/week × 3 weeks. Next visit: lower the sit-to-stand surface; add a loaded carry if lateral trunk control holds. Re-measure flexion and re-run the instability test at visit 8. Home programme unchanged this week.
S, line by line
| Weak | Strong | Why |
|---|---|---|
| “Patient reports feeling better.” | “Pain 4/10, was 6/10 at evaluation.” | A number that can be compared next visit |
| “Doing her exercises.” | “5 of 7 days; skipped prone extensions twice.” | Adherence is data, and it explains the plan |
| “Worse with sitting.” | “Worst on rising after 30+ minutes.” | Names the provocation and the threshold |
The subjective section is where the patient’s week enters the record. Two numbers and a provocation is enough; a paragraph of narrative is not better.
O, line by line
Measurements first, then interventions with minutes. The minutes are not decoration: the units on the claim are constrained by the day’s total, which is what the units calculator computes. A note with no minutes forces a reviewer to assume the lower number.
Each intervention carries its dosage and the skilled input — the cue, the grade, the progression. “Therex as tolerated” contains none of those and is the single most common line in outpatient charts.
A, the section that decides
The assessment is the only section that argues. It links what changed to why a licensed clinician was required, and it is the section reviewers read first and quote back.
“Tolerated treatment well” is true of every patient on every day, which is what makes it worthless.
The strong version above does two jobs in two clauses: it states the measured change, and it states the reason the next repetition still needs supervising. That second clause is the whole case for the visit.
P, and what happens next
Frequency, duration and the specific next step. “Continue plan of care” tells a reviewer nothing and tells the next clinician nothing either — including you, in a fortnight, when the patient is on someone else’s schedule.
Name the progression you intend and the measurement you will re-take. If the plan itself needs to change, that is a re-evaluation with its own code and its own criteria; the evaluation code guide covers where that line sits.
Write it in the room
A note written at 7pm from memory loses the numbers first — which are the part that matters. Two minutes at the end of the visit beats twenty at the end of the day.
Red flag — refer out
No sentence structure rescues a missed red flag. Night pain that wakes the patient, saddle anaesthesia, progressive weakness or unexplained weight loss ends the episode and starts a referral.
Sources
- CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 5 §20.2.C — counting minutes for timed codes in 15-minute units · read 2026-09-04
- American Medical Association — Current Procedural Terminology (CPT) — CPT is an AMA trademark; the official descriptors are the AMA's and are paraphrased here, never reproduced · read 2026-09-04
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Published 2026-09-04 · reviewed 2026-09-04