Physical Therapy NotesSOAP Note Templates & Examples
Complete guide to PT documentation including SOAP notes, initial evaluations, progress notes, and discharge summaries. With real examples, templates, and Medicare-compliant documentation strategies.
What Makes Effective PT Documentation?
Physical therapy documentation serves multiple critical purposes: it communicates patient status to other providers, justifies medical necessity for insurance, protects you legally, and tracks patient progress. Well-written PT notes tell a clear story of why therapy is needed, what you're doing, and how it's helping.
The SOAP format remains the gold standard for PT treatment notes, providing a logical structure that payers, auditors, and other healthcare providers expect. Each section serves a specific purpose in building your case for skilled intervention.
AI documentation tools like PatientNotes can reduce PT charting time by 50%+ while ensuring consistent, compliant documentation that supports reimbursement.
Common PT Outcome Measures
Use standardized outcome measures to objectively track patient progress. These tests are essential for Medicare compliance and quality reporting.
Mobility & Balance
| Test | Normal | Clinical Cutoff |
|---|---|---|
| Timed Up and Go (TUG) | <10 sec | >14 sec = fall risk |
| 6-Minute Walk Test | >400m | <300m = significant impairment |
| Berg Balance Scale | 56/56 | <45 = fall risk |
| 5x Sit to Stand | <12 sec | >15 sec = impaired |
| 10-Meter Walk Test | >1.2 m/s | <0.8 m/s = community limited |
Patient-Reported Outcomes
| Test | Normal | Clinical Cutoff |
|---|---|---|
| Oswestry Disability Index | 0-20% | MCID: 10 points |
| Neck Disability Index | 0-20% | MCID: 10 points |
| LEFS (Lower Extremity) | 80/80 | MCID: 9 points |
| DASH (Upper Extremity) | 0 | MCID: 10 points |
| NPRS (Pain) | 0/10 | MCID: 2 points |
PT Documentation Templates
Comprehensive templates for all types of physical therapy documentation. Each includes required elements and real-world examples.
Initial Evaluation
Comprehensive assessment establishing baseline function, diagnosis, and treatment plan.
Required Elements:
Example:
PHYSICAL THERAPY INITIAL EVALUATION Date: 12/18/2024 Therapist: Michael Chen, PT, DPT PATIENT INFORMATION: Name: Jennifer Martinez DOB: 08/14/1972 Diagnosis: L4-5 lumbar disc herniation with left radiculopathy (M51.16) Referral: Dr. Thompson, Orthopedic Surgery Date of Onset: 11/01/2024 HISTORY: Chief Complaint: "Low back pain with shooting pain down my left leg" HPI: 52 y/o female presents with 7-week history of LBP and left LE radicular symptoms. Pain began insidiously while gardening, progressively worsening. MRI (11/15/24) confirmed L4-5 disc herniation with left L5 nerve root compression. Pain is 7/10 at worst, 4/10 at best. Aggravated by prolonged sitting (>20 min), bending, lifting. Relieved by lying down, walking short distances. Currently on gabapentin 300mg TID with minimal relief. PMH: Hypertension, hypothyroidism PSH: C-section x2 Medications: Gabapentin 300mg TID, Lisinopril 10mg daily, Levothyroxine 75mcg daily Allergies: NKDA Prior Level of Function: Independent in all activities. Works as administrative assistant (desk job). Active - walks 2 miles daily, yoga 2x/week. Lives in single-story home with husband. Goals: Return to work full duty, resume walking and yoga SYSTEMS REVIEW: Cardiovascular: WNL Integumentary: Intact Musculoskeletal: Impaired - see below Neuromuscular: Impaired - see below Communication/Cognition: WNL TESTS AND MEASURES: Posture: Decreased lumbar lordosis, left lateral shift Gait: Antalgic, shortened left stance phase, decreased arm swing Range of Motion - Lumbar Spine: - Flexion: 40% (limited by LBP and left LE symptoms) - Extension: 25% (centralizes symptoms - positive) - Left SB: 75% - Right SB: 50% (peripheralizes) - Left rotation: 80% - Right rotation: 60% Strength (L5 myotome): - Left hip abduction: 4/5 (R: 5/5) - Left ankle dorsiflexion: 4-/5 (R: 5/5) - Left great toe extension: 3+/5 (R: 5/5) Sensation: - Diminished light touch left lateral leg and dorsal foot (L5 dermatome) Reflexes: - Patellar: 2+ bilateral - Achilles: 2+ right, 1+ left Special Tests: - SLR: Positive left at 45° (reproduces radicular symptoms) - Slump test: Positive left - Prone instability test: Negative - FABER: Negative bilateral Palpation: Tenderness left L4-5 paraspinals, left piriformis STANDARDIZED OUTCOME MEASURES: - Oswestry Disability Index: 48% (Severe disability) - NPRS: 7/10 current, 4/10 best, 9/10 worst - Fear Avoidance Beliefs (FABQ-W): 28 (elevated) CLINICAL IMPRESSION: 52 y/o female with L4-5 disc herniation and left L5 radiculopathy. Presents with moderate-severe functional limitations, positive neural tension signs, and mild L5 motor weakness. Favorable prognostic indicators include: centralization with extension, no progressive neurological deficit, high motivation. Good rehab potential. GOALS: Short-Term Goals (4 weeks): 1. Patient will demonstrate pain reduction to 3/10 or less with ADLs 2. Patient will tolerate sitting 45 minutes for return to modified work duties 3. Patient will demonstrate independence with HEP including McKenzie extension protocol 4. Patient will demonstrate lumbar AROM 75% of normal in all planes Long-Term Goals (8 weeks): 1. Patient will return to full work duties without limitations 2. Patient will achieve Oswestry score <20% (minimal disability) 3. Patient will return to walking 2 miles without symptom exacerbation 4. Patient will demonstrate full L5 motor strength (5/5) PLAN OF CARE: Frequency: 2x/week for 4 weeks, then 1x/week for 4 weeks Total visits: 12 Interventions: - Manual therapy: HVLA thrust manipulation, soft tissue mobilization - Therapeutic exercise: McKenzie extension, core stabilization, nerve glides - Neuromuscular re-education: postural training, body mechanics - Patient education: ergonomics, activity modification, HEP - Modalities PRN: IFC for pain modulation Medical Necessity: Skilled PT required to address lumbar disc herniation with radiculopathy causing significant functional limitations. Patient requires directional preference assessment, manual therapy, and progressive exercise that cannot be safely performed independently. Potential to avoid surgical intervention with conservative management. Patient in agreement with plan. HEP instructed today. _____________________________ Michael Chen, PT, DPT License #: PT45678
Daily Treatment Note (SOAP)
Session-by-session documentation of treatment provided.
Required Elements:
Example:
PHYSICAL THERAPY TREATMENT NOTE Date: 12/18/2024 | Time: 2:00 PM | Duration: 45 min Therapist: Michael Chen, PT, DPT Patient: Jennifer Martinez | DOB: 08/14/1972 Dx: L4-5 disc herniation with L radiculopathy | Visit: 4 of 12 SUBJECTIVE: Patient reports, "The leg pain is definitely better. I can sit longer at my desk now." Current pain: LBP 4/10 (↓ from 7/10), left leg 2/10 (↓ from 6/10). States she has been compliant with HEP - extension exercises 4x/day. Able to sit 35 min before needing position change (↑ from 20 min baseline). Sleeping better - only waking 1x/night vs 3x. No new complaints. OBJECTIVE: Interventions Provided: 1. Manual Therapy (15 min) - 97140 - Lumbar HVLA thrust manipulation L4-5 (1 rep, right rotation) - STM to left piriformis and lumbar paraspinals - L5 nerve mobilization (grade 3) - Patient response: Immediate improvement in SLR to 60° 2. Therapeutic Exercise (15 min) - 97110 - Prone press-ups: 3x10 (maintains centralization) - Cat-camel: 3x10 for segmental mobility - Dead bug progression: 3x10 each side - Bird-dog: 3x10 each side - Standing hip hinge with dowel: 3x10 3. Neuromuscular Re-education (15 min) - 97112 - Sitting posture training with lumbar roll - Standing-to-sitting mechanics - Lifting mechanics with 5 lb weight - Work station ergonomic simulation Measurements: - Lumbar flexion: 60% (↑ from 40% eval) - Lumbar extension: 50% (↑ from 25% eval) - SLR left: 60° (↑ from 45° eval) - Left ankle DF strength: 4/5 (stable) - NPRS: 4/10 (↓ from 7/10 eval) Treatment Tolerance: Good. No adverse reactions. Symptoms centralized with extension activities. ASSESSMENT: Patient progressing well toward all goals. Significant improvement in radicular symptoms and sitting tolerance. Centralization pattern maintained. Left L5 motor function stable - will continue to monitor. FABQ-W likely improving with successful activity tolerance. Continue current POC. Goal Progress: STG 1 (Pain ≤3/10): Progressing - currently 4/10 STG 2 (Sit 45 min): Progressing - currently 35 min STG 3 (Independent HEP): MET STG 4 (AROM 75%): Progressing - extension at 50% PLAN: Continue PT 2x/week per POC Next session: - Progress core stabilization - Add walking program - Work simulation activities - Assess readiness for modified return to work HEP updated: Added dead bug and bird-dog to home program _____________________________ Michael Chen, PT, DPT
Progress Note / Re-evaluation
Periodic assessment required for Medicare and insurance authorization.
Required Elements:
Example:
PHYSICAL THERAPY PROGRESS NOTE / RE-EVALUATION Date: 01/08/2025 Therapist: Michael Chen, PT, DPT Patient: Jennifer Martinez | DOB: 08/14/1972 Dx: L4-5 disc herniation with L radiculopathy Treatment Period: 12/04/2024 - 01/08/2025 Visits Completed: 8 of 12 TREATMENT SUMMARY: Patient attended 8 of 8 scheduled visits (100% compliance). Treatment focused on manual therapy (thrust manipulation, STM, nerve mobilization), directional preference exercises (McKenzie), core stabilization, and functional training for return to work. OUTCOME MEASURE COMPARISON: | Measure | Baseline | Current | Change | MCID | |---------|----------|---------|--------|------| | Oswestry (%) | 48 | 22 | -26 | 10 | | NPRS (avg) | 7/10 | 2/10 | -5 | 2 | | FABQ-W | 28 | 12 | -16 | 7 | | Sitting tolerance | 20 min | 60 min | +40 min | -- | CURRENT PHYSICAL STATUS: Range of Motion - Lumbar: - Flexion: 90% (baseline 40%) - Extension: 85% (baseline 25%) - All other planes: WFL Strength: - Left ankle DF: 4+/5 (baseline 4-/5) - Left great toe ext: 4/5 (baseline 3+/5) - Core stability: Good Special Tests: - SLR left: 75° (baseline 45°) - minimal reproduction - Slump: Negative (baseline positive) Functional Status: - Returned to modified work duty 12/30/24 - Walking 1 mile daily without symptoms - ADLs independent GOAL STATUS: | Goal | Status | |------|--------| | STG 1: Pain ≤3/10 with ADLs | MET (2/10) | | STG 2: Sit 45 min for work | MET (60+ min) | | STG 3: Independent HEP | MET | | STG 4: AROM 75% | MET (85-90%) | | LTG 1: Full work duties | PROGRESSING | | LTG 2: Oswestry <20% | PROGRESSING (22%) | | LTG 3: Walk 2 miles | PROGRESSING (1 mile) | | LTG 4: L5 strength 5/5 | PROGRESSING (4+/5) | CLINICAL IMPRESSION: Excellent progress. All STGs met ahead of schedule. Patient has returned to modified work and progressing toward full duties. Radicular symptoms largely resolved. Minimal residual motor weakness continuing to improve. Patient motivated to complete rehabilitation and return to full activity. REVISED GOALS (4 weeks): 1. Return to full work duties without restrictions 2. Oswestry <10% (minimal disability) 3. Walk 2 miles without symptoms 4. Left L5 myotome strength 5/5 5. Return to yoga with modifications UPDATED PLAN: Reduce frequency to 1x/week for 4 weeks (4 additional visits) Total authorized: 12 | Completed: 8 | Remaining: 4 Focus: - Progress to full work simulation - Walking/cardio progression - Return to exercise activities - Discharge planning Medical Necessity: Continued skilled PT required to complete return to full function. Patient has made excellent progress but has not yet achieved maximum functional capacity. Specific deficits remaining include mild L5 weakness and incomplete return to full work/recreational activities. _____________________________ Michael Chen, PT, DPT
Discharge Summary
Final documentation upon completion of PT services.
Required Elements:
Example:
PHYSICAL THERAPY DISCHARGE SUMMARY Date: 02/05/2025 Therapist: Michael Chen, PT, DPT Patient: Jennifer Martinez | DOB: 08/14/1972 Dx: L4-5 disc herniation with L radiculopathy Treatment Period: 12/04/2024 - 02/05/2025 Total Visits: 12 REASON FOR DISCHARGE: Goals met. Patient achieved full return to work and recreational activities. TREATMENT SUMMARY: Patient received skilled PT 2x/week for 4 weeks, then 1x/week for 8 weeks. Interventions included: - Manual therapy: Spinal manipulation, soft tissue mobilization, neural mobilization - Therapeutic exercise: McKenzie directional preference, core stabilization progression - Neuromuscular re-education: Postural training, body mechanics, lifting mechanics - Functional training: Work simulation, sport-specific training - Patient education: Ergonomics, injury prevention, self-management OUTCOME COMPARISON: | Measure | Baseline | Discharge | Change | Status | |---------|----------|-----------|--------|--------| | Oswestry (%) | 48 | 6 | -42 | Exceeded | | NPRS | 7/10 | 0-1/10 | -6 | Exceeded | | FABQ-W | 28 | 4 | -24 | Exceeded | | Lumbar flexion | 40% | 100% | +60% | Met | | L5 strength | 3+/5 | 5/5 | +1.5 | Met | GOAL OUTCOMES: All long-term goals met: ✓ Returned to full work duties without restrictions (01/27/25) ✓ Oswestry 6% (goal <10%) ✓ Walking 2+ miles without symptoms ✓ L5 strength 5/5 bilateral ✓ Returned to yoga 2x/week with full participation DISCHARGE FUNCTIONAL STATUS: - Pain: 0-1/10 (rare, brief, self-limiting) - Work: Full duty, no restrictions - ADLs: Independent without limitations - Recreation: Walking 2 miles daily, yoga 2x/week - Sleeping: Through the night without pain HOME EXERCISE PROGRAM: Written HEP provided. Patient demonstrates independence with: 1. Lumbar extension stretches (daily or PRN) 2. Core stabilization exercises (3x/week) 3. Hip and hamstring stretching 4. Walking program (continue 2 miles daily) 5. Return to yoga with awareness of extension bias PATIENT EDUCATION PROVIDED: - Ergonomic workstation setup (completed at work) - Proper lifting mechanics - Activity modification strategies - Warning signs requiring medical attention - Self-management for flare-ups RECOMMENDATIONS: 1. Continue home program independently 2. May return to all activities without restriction 3. No anticipated need for further PT at this time 4. Return to PT if symptoms recur or new functional limitations develop 5. Annual wellness check with PCP DISCHARGE DISPOSITION: Discharged to independent self-management. Patient and family educated on home program and flare-up management. Emergency contact provided. Prognosis: Excellent. Patient achieved all goals and demonstrates knowledge for independent management. _____________________________ Michael Chen, PT, DPT License #: PT45678
PT Documentation Best Practices
Follow these guidelines to create documentation that supports reimbursement, protects you legally, and communicates effectively.
Show Skilled Care
Document WHY your intervention requires the skills of a licensed PT. What clinical reasoning, assessment, or specialized technique is involved?
Use Objective Measurements
Include specific ROM in degrees, strength grades (0-5), distances, times, and standardized test scores. Avoid vague terms like "improved" without data.
Document Medical Necessity
Clearly explain why PT services are needed and what would happen without them. Link interventions to functional limitations.
Track Goal Progress
Every note should reference established goals. Are they being met? What barriers exist? Update goals as needed.
Include Patient Response
Document how the patient responded to treatment - both positive outcomes and any adverse reactions or limitations.
Be Specific with Time
Document skilled treatment time for each CPT code. Medicare requires 8-minute rule compliance for timed codes.
Medicare 8-Minute Rule for PT Billing
For timed CPT codes, Medicare requires documentation of total treatment minutes. Use this guide for proper unit billing:
| Total Minutes | Billable Units |
|---|---|
| 8-22 minutes | 1 unit |
| 23-37 minutes | 2 units |
| 38-52 minutes | 3 units |
| 53-67 minutes | 4 units |
| 68-82 minutes | 5 units |
Remember: Document actual treatment time for each timed code. The 8-minute rule applies to the total skilled treatment time, not individual interventions. At least one timed code must have at least 8 minutes.
Frequently Asked Questions
What is a physical therapy SOAP note?
A PT SOAP note is a structured documentation format using Subjective (patient report), Objective (measurements and clinical findings), Assessment (clinical analysis and progress), and Plan (treatment plan) sections to record therapy sessions.
How long should PT documentation take?
A daily treatment note should take 5-10 minutes. Initial evaluations may take 15-20 minutes. AI documentation tools can reduce this time by 50% while improving completeness.
What are the Medicare documentation requirements for PT?
Medicare requires: functional outcome measures, skilled intervention documentation, progress toward goals, medical necessity justification, certification/recertification every 90 days, and therapy cap tracking.
Can physical therapy assistants (PTAs) write treatment notes?
Yes, PTAs can document treatment sessions they provide. However, initial evaluations, re-evaluations, and discharge summaries must be completed by a licensed PT. PTA notes should indicate PT supervision as required.
What standardized tests should be documented in PT notes?
Common PT outcome measures include: Timed Up and Go (TUG), 6-Minute Walk Test, Berg Balance Scale, Oswestry Disability Index, LEFS, DASH, and Visual Analog Scale for pain. Document baseline and progress scores.
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