Physical Therapy SOAP Notes: Complete Documentation Guide
Master PT documentation with this comprehensive guide to SOAP notes. Learn proper format with ROM measurements, strength testing, functional outcomes, and Medicare requirements. Includes complete examples of initial evaluations, progress notes, and discharge summaries.
Physical Therapy Documentation
Why Physical Therapy Documentation Matters
Physical therapy documentation serves as the foundation for patient care, legal protection, and reimbursement. According to APTA, physical therapists spend approximately 27% of their work time on documentation, making it a critical professional skill that directly impacts practice sustainability and patient outcomes.
Medical Necessity
Justifies skilled PT services and differentiates from maintenance or wellness programs
Legal Protection
Provides defensible record of evaluation, treatment, and clinical decision-making
Reimbursement
Demonstrates skilled services for insurance payment and Medicare compliance
Communication
Shares findings and progress with physicians, patients, and interdisciplinary team
Outcomes Tracking
Measures progress with standardized tools and functional outcome measures
Quality Assurance
Supports evidence-based practice and quality reporting programs like FOTO
APTA Documentation Standards
The American Physical Therapy Association requires documentation to be: timely (completed within facility timeframes), accurate (objective and measurable), comprehensive (all relevant findings), and legible (EHR or clearly written). Documentation must support medical necessity and skilled service provision.
SOAP Format for Physical Therapy
The SOAP note format provides a structured approach to PT documentation that meets regulatory requirements while capturing comprehensive patient information.
Subjective
Patient-Reported Information
Document the patient's perspective including chief complaint, pain levels, functional limitations, and goals
Key Elements to Document:
Pro Tip:
Use direct quotes when possible. Document pain with the OPQRST method: Onset, Provocation, Quality, Region/Radiation, Severity, Timing.
Objective
Measurable Clinical Findings
Quantifiable data from your examination including ROM, strength, special tests, gait analysis, and functional assessments
Key Elements to Document:
Pro Tip:
Always include numerical measurements. Document bilateral comparisons. Use standardized outcome measures (FOTO, LEFS, DASH, etc.).
Assessment
Clinical Interpretation
Your professional analysis synthesizing subjective and objective data into a clinical picture and prognosis
Key Elements to Document:
Pro Tip:
Connect findings to functional limitations. Justify skilled services. Update prognosis based on progress. Reference standardized measures.
Plan
Treatment Strategy
Detailed plan for ongoing treatment including frequency, duration, interventions, and progression strategies
Key Elements to Document:
Pro Tip:
Be specific with exercise prescriptions. Document medical necessity for continued skilled services. Update plan based on response.
Complete PT SOAP Note Examples
These comprehensive examples demonstrate proper documentation for different note types with realistic measurements, clinical reasoning, and Medicare-compliant language.
Initial Evaluation
Outpatient Orthopedics - Rotator Cuff Tendinopathy
PHYSICAL THERAPY INITIAL EVALUATION
Date: 01/15/2025 Time: 10:00 AM
Patient: John Smith DOB: 03/22/1978 (46 yo)
Diagnosis: Right shoulder impingement syndrome, rotator cuff tendinopathy
Physician: Dr. Sarah Johnson, MD Script Date: 01/10/2025
SUBJECTIVE
----------
Chief Complaint: "I have constant pain in my right shoulder that's affecting my work and sleep."
History of Present Illness: Patient is a 46-year-old male carpenter who reports gradual onset of right shoulder pain over the past 3 months. Denies specific traumatic event. Patient describes pain as "deep aching" that becomes "sharp and stabbing" with overhead activities. Pain rated 3/10 at rest, 7-8/10 with overhead reaching. Reports significant difficulty with work tasks requiring overhead activity (painting, installing cabinets). Sleep disrupted 4-5 nights per week due to pain when rolling onto right shoulder.
Pain Pattern:
- Location: Anterolateral shoulder, radiates to deltoid insertion
- Quality: Deep ache at rest, sharp with movement
- Intensity: 3/10 at rest, 7-8/10 with activity
- Aggravating: Overhead reaching, lifting >10 lbs, lying on right side
- Alleviating: Ice, rest, NSAIDs (moderate relief)
- 24-hr pattern: Worse in evening after work, morning stiffness ~30 min
Functional Limitations:
- Unable to reach overhead for work tasks (0% tolerance)
- Difficulty with self-care: washing hair, reaching to back pocket
- Cannot lift tools overhead (previously lifted up to 40 lbs)
- Avoids recreational softball due to pain
Prior Treatment: Self-treated with ice and ibuprofen 400mg TID with partial relief. No prior PT.
Medical History: No previous shoulder injuries. Hypertension controlled with lisinopril. Non-smoker.
Patient Goals:
1. Return to work without restrictions (full duty carpenter)
2. Sleep through the night without shoulder pain
3. Return to recreational softball
OBJECTIVE
---------
Observation:
- Posture: Forward head posture, rounded shoulders bilaterally, right shoulder held in slight internal rotation
- Gait: Normal pattern, arms swing symmetrically
- Assistive devices: None required
Palpation:
- Point tenderness over anterior shoulder at bicipital groove (4/10 pain)
- Tenderness over subacromial space (5/10 pain)
- Mild warmth, no visible swelling
- Upper trapezius hypertonicity bilaterally, worse on right
Range of Motion (goniometric measurements):
Right Left WNL
Flexion 142° 175° 180°
Abduction 135° (pain) 178° 180°
External Rotation 52° 88° 90°
Internal Rotation T12 level T8 level T8
Horizontal Add 85° 125° 130°
Pain with active ROM at end-range flexion and abduction (6/10).
Painful arc present 70-120° abduction.
Manual Muscle Testing (0-5 scale):
Right Left
Flexion 4/5 5/5
Abduction 4-/5 (pain) 5/5
External Rotation 3+/5 5/5
Internal Rotation 4/5 5/5
Scapular muscles:
- Serratus anterior: 3+/5 (winging noted with wall push-up)
- Middle/Lower trap: 3/5 bilaterally
- Rhomboids: 3+/5
Special Tests:
- Neer's impingement: Positive (+) right shoulder
- Hawkins-Kennedy: Positive (+) right shoulder
- Empty can (Jobe's): Positive (+) for pain and weakness right shoulder
- Drop arm test: Negative (-)
- Lift-off test: Unable to perform due to pain/weakness
Neurological Screening:
- Dermatomes C5-T1: Intact bilaterally
- Myotomes C5-T1: Weakness noted as above in shoulder, otherwise intact
- Reflexes (biceps, triceps): 2+ bilaterally, symmetrical
- Upper limb tension test: Negative
Functional Assessment:
- Reaching to overhead shelf: Requires compensation with trunk side-bending, pain 7/10
- Simulated hammering overhead: Unable to perform >5 repetitions due to pain
- Modified DASH: 42/100 (higher score = greater disability)
- PENN Shoulder Score: 54/100 (lower score = greater disability)
Treatment Provided Today:
- Joint mobilization: Grade III posterior glide, improved ER ROM by 8°
- Soft tissue mobilization to upper trapezius, anterior shoulder
- Therapeutic exercise: Scapular stabilization exercises (rows, Ws, Ys)
- Modalities: Ice 15 minutes post-treatment
- Patient education: Activity modification, posture correction
Patient Response: Tolerated initial treatment well. Reports pain decreased from 4/10 to 2/10 post-treatment. Demonstrated good understanding of HEP.
ASSESSMENT
----------
Physical Therapy Diagnosis: Right shoulder impingement syndrome with rotator cuff tendinopathy and scapular dyskinesis.
Impairments (Body Structure/Function):
- ROM deficits: Flexion (-38°), abduction (-45°), ER (-38°) right shoulder
- Strength deficits: External rotators (3+/5), scapular stabilizers (3-3+/5)
- Pain with overhead activities (7-8/10)
- Postural dysfunction: Forward head, rounded shoulders
- Scapular dyskinesis: Poor neuromuscular control, winging present
Activity Limitations:
- Unable to perform overhead work tasks (carpentry) 0/100%
- Difficulty with ADLs: dressing, grooming requiring shoulder elevation
- Modified DASH 42/100 indicates moderate functional limitation
Participation Restrictions:
- Unable to work full duty (currently on light duty restrictions)
- Cannot participate in recreational softball
- Sleep disruption 4-5 nights/week affecting quality of life
Response to Treatment: Positive initial response to manual therapy with immediate ROM improvement. Patient demonstrated good body awareness and exercise technique.
Prognosis: Good to excellent. Patient is motivated, generally healthy, and demonstrates good movement patterns with cueing. Expected to return to full work duties and recreational activities.
Rehabilitation Potential: Excellent for return to prior level of function with skilled PT intervention including manual therapy, therapeutic exercise, and activity-specific training.
PLAN
----
Frequency/Duration: 2x/week for 6 weeks, then reassess (12 visits)
Treatment Interventions:
1. Manual Therapy:
- Joint mobilization: Posterior/inferior glenohumeral glides (Grade III-IV)
- Soft tissue mobilization: Upper trapezius, pectoralis minor, anterior shoulder
2. Therapeutic Exercise:
- Scapular stabilization progression (isometric → dynamic)
- Rotator cuff strengthening (progressive resistance)
- Postural training and thoracic mobility
- Progressive overhead strengthening program
3. Neuromuscular Re-education:
- Scapulohumeral rhythm training
- Movement pattern correction for work tasks
4. Modalities: Ice PRN for pain management
5. Patient Education:
- Activity modification strategies for work
- Ergonomic positioning
- Sleep positioning to minimize pain
Home Exercise Program (HEP):
- Pendulum exercises 2x/day for pain relief
- Scapular retraction (rows with resistance band) 2x15, daily
- External rotation strengthening (sidelying) 2x15, daily
- Wall slides for shoulder elevation 2x10, daily
- Postural exercises (chin tucks, scapular setting) throughout day
- Ice 15 min after HEP or aggravating activities
Short-Term Goals (3 weeks):
1. Decrease pain to 2/10 at rest, 4/10 with activity
2. Increase shoulder flexion ROM to 165°
3. Increase ER strength to 4/5
4. Improve scapular stabilizer strength to 4/5
5. Demonstrate independent HEP with proper form
Long-Term Goals (6 weeks):
1. Pain 0-1/10 with all activities including overhead work
2. Restore full shoulder ROM bilaterally symmetrical
3. Restore 5/5 strength all shoulder and scapular muscles
4. Return to full duty work without restrictions
5. Modified DASH score <15 (minimal disability)
6. Independent with advanced exercise program for long-term maintenance
Plan for Progression:
- Week 1-2: Focus on pain reduction, ROM, basic strengthening
- Week 3-4: Progress resistance, introduce functional movements
- Week 5-6: Work-specific training, sport-specific activities, discharge planning
Next Visit: 01/17/2025 - Progress ROM and strengthening, reassess pain and functional abilities
Medical Necessity: Skilled PT services required for manual therapy techniques, exercise prescription/progression, neuromuscular re-education, and work-specific training that cannot be self-taught.
___________________________
Physical Therapist Signature
Lic #: PT123456
Date: 01/15/2025Progress Note
Outpatient Orthopedics - ACL Reconstruction Post-Op
PHYSICAL THERAPY PROGRESS NOTE
Date: 02/08/2025 Visit #: 8 of 20
Patient: Maria Garcia DOB: 05/14/2001 (23 yo)
Diagnosis: S/P Right ACL reconstruction (hamstring autograft)
Surgery Date: 01/10/2025 Surgeon: Dr. Michael Chen, MD
Post-Op Week: 4 weeks
SUBJECTIVE
----------
Patient reports: "My knee is feeling much stronger and I'm walking without crutches now!"
Pain: Reports pain has decreased significantly. Currently 1-2/10 at rest, 3-4/10 with exercise. No night pain. Denies any sharp, catching, or locking sensations.
Swelling: Minimal swelling, "much better than last week." Using ice 2x/day as recommended.
Function: Ambulating independently without assistive device since 2 days ago. Able to perform ADLs without difficulty. Returned to work (office job, sedentary) this week without issues. Performing HEP 2x/day as prescribed. Reports compliance with brace use during ambulation as ordered.
Concerns: Asking about timeline for return to running and soccer (recreational player).
OBJECTIVE
---------
Observation:
- Gait: Normal pattern without assistive device, no antalgic gait
- Effusion: Minimal, stroke test negative today (previously trace positive)
- Surgical incision: Well-healed, no signs of infection, minimal scarring
- Wearing post-op brace unlocked 0-90° per MD protocol
Range of Motion (goniometric):
Current (2/8) Previous (2/1) Goal Uninvolved
Flexion 118° 105° 135° 142°
Extension -3° -5° 0° 0°
Progress: Flexion improved 13° this week, extension improved 2°
Manual Muscle Testing:
Current Previous Uninvolved
Quad (extension) 4-/5 3+/5 5/5
Hamstring 4/5 4-/5 5/5
Hip abductors 4+/5 4/5 5/5
Hip extensors 4+/5 4/5 5/5
Circumference (cm) - 10cm above patella:
Right: 42 cm Left: 44 cm Difference: 2 cm (improved from 3 cm last week)
Functional Tests:
- Straight leg raise: Performs without lag, good quad control
- Heel slides: Full active flexion without assistance
- Mini squats (0-45°): 3x15 with good form, symmetrical weight bearing
- Step-ups (4" step): 2x10 each leg, right knee stable, no valgus collapse
- Single leg stance: 30 seconds on right with eyes open (steady)
- Balance (BESS test): 2 errors right leg vs 0 errors left leg
Treatment Provided Today:
- Patellar mobilization (superior/inferior glides)
- Soft tissue mobilization: Quadriceps, hamstrings, iliotibial band
- Therapeutic exercise:
* Wall slides: 3x15
* Hamstring curls (5 lbs): 3x12
* Leg press (30 lbs): 3x10
* Step-ups progressed to 6" height: 3x10
* Balance training: Single leg stance on foam
* Stationary bike: 10 minutes, no resistance (ROM)
- Cryotherapy: 15 minutes post-treatment
Patient Response: Tolerated treatment well. No increase in pain or swelling during or after session. Demonstrating improved quad activation and control.
OBJECTIVE OUTCOME MEASURES:
- IKDC Subjective Knee Form: 64.4 (improved from 52.3 at initial eval)
- Lower Extremity Functional Scale (LEFS): 56/80 (improved from 42/80)
ASSESSMENT
----------
Patient is a 23-year-old female currently 4 weeks post-op right ACL reconstruction progressing well toward goals. Demonstrates excellent progress this week with significant improvements in ROM, strength, and function.
Impairment Progress:
- ROM: 78% toward goal for flexion, 40% toward goal for extension
- Strength: Quad strength improved from 3+/5 to 4-/5 (60% toward goal)
- Swelling: Minimal effusion, well-controlled with ice and elevation
- Gait: Normalized, no longer requires assistive device
Functional Progress:
- Ambulation: Independent without device (goal met)
- ADLs: Independent without pain (goal met)
- LEFS: Improved 14 points (minimal clinically important difference = 9 points)
- IKDC: Improved 12.1 points (approaching age-matched norms)
Response to Treatment: Excellent. Patient showing appropriate healing timeline consistent with ACL reconstruction protocol. No complications noted. Patient highly compliant with HEP and precautions.
Progress Toward Goals:
1. Full ROM: 78% achieved (on track for 6-week goal)
2. 4+/5 quad strength: 80% achieved (ahead of schedule)
3. Independent ADLs: 100% achieved ✓
4. LEFS >60: 93% achieved (56/60)
Overall Progress: Patient progressing ahead of expected timeline. Meeting post-op week 4 protocol benchmarks. Prognosis remains excellent for full return to sport at 6-9 months.
Barriers: None identified at this time.
PLAN
----
Continue PT 2x/week for 4 weeks, then reassess frequency
Treatment Focus:
1. Continue ROM exercises with goal of full extension by week 6
2. Progressive resistance training for quadriceps and hamstrings
3. Advance balance and proprioception training
4. Initiate light plyometric exercises per MD protocol (week 5+)
5. Continue patellar mobilization and soft tissue techniques
6. Pool therapy to be initiated next week for gait training and resistance exercises
Updated HEP:
- Stationary bike: 15 min daily for ROM
- Heel slides: 3x20 daily
- Quad sets: 3x20 with 5-second holds, daily
- Straight leg raises (4 directions): 2x15 each, daily
- Mini squats: 3x15 daily
- Step-ups (6"): 2x15 each leg, daily
- Balance exercises: Single leg stance 3x30 sec, 2x/day
- Ice after exercises 15-20 minutes
Short-Term Goals (Next 2 weeks):
1. Achieve full knee extension (0°)
2. Improve flexion to 130°
3. Quad strength to 4+/5
4. Progress to bilateral squats (0-90°)
5. Initiate pool-based plyometrics
Long-Term Goals (Continue toward):
1. Full ROM equal to uninvolved side
2. 5/5 strength all lower extremity muscles
3. Return to recreational soccer at 6-9 months post-op per MD clearance
4. IKDC score >85
5. Pass return-to-sport testing battery
Progression Criteria: Will advance to running program when patient demonstrates: full ROM, quad strength ≥80% of uninvolved, no effusion, single leg hop >90% limb symmetry (estimated 12-16 weeks post-op).
Communication: Progress update sent to Dr. Chen. Patient progressing well per protocol.
Next Visit: 02/10/2025 - Continue strengthening progression, initiate pool therapy
___________________________
Physical Therapist Signature
Lic #: PT789012
Date: 02/08/2025Discharge Summary
Outpatient Orthopedics - Lumbar Strain
PHYSICAL THERAPY DISCHARGE SUMMARY
Date: 03/15/2025 Total Visits: 8
Patient: Robert Thompson DOB: 09/03/1985 (39 yo)
Diagnosis: Lumbar strain, mechanical low back pain
Initial Evaluation: 02/01/2025
Referring Physician: Dr. Patricia Lee, MD
SUMMARY OF CARE
---------------
Initial Presentation (02/01/2025):
Patient presented with acute low back pain following incident at work (lifting heavy box with poor mechanics) 2 weeks prior. Pain rated 6-7/10 at rest, 8-9/10 with forward bending and prolonged sitting. Significant functional limitations with work duties (warehouse supervisor) and ADLs.
Initial Objective Findings:
- ROM: Lumbar flexion 30° (limited by pain), extension 10°, side-bending 15° bilaterally
- Strength: Core musculature 3/5, hip extensors 4-/5 bilaterally
- Straight leg raise: Negative bilaterally
- Neurological exam: Intact
- Oswestry Disability Index (ODI): 52% (severe disability)
- Functional Rating Index (FRI): 68% disability
Treatment Provided:
Frequency: 2x/week for 6 weeks (12 visits total; patient missed 4 appointments)
Interventions:
1. Manual Therapy:
- Soft tissue mobilization to lumbar paraspinals, quadratus lumborum
- Joint mobilization: Central PAs to lumbar spine (Grade III-IV)
2. Therapeutic Exercise:
- Core stabilization progression (dead bug, bird dog, planks)
- Flexibility program (hip flexors, hamstrings, lumbar spine)
- Progressive strengthening: Bridges, squats, deadlift mechanics
3. Neuromuscular Re-education:
- Proper lifting mechanics training
- Movement pattern correction
- Ergonomic training for work tasks
4. Modalities: Ice/heat as needed for pain management
5. Patient Education:
- Pain neuroscience education
- Activity pacing and body mechanics
- Self-management strategies
Home Exercise Program:
Patient provided with comprehensive HEP including core strengthening, flexibility exercises, and proper body mechanics. Patient demonstrated independence with program.
DISCHARGE STATUS (03/15/2025)
-----------------------------
Subjective:
Patient reports: "I'm back to work full-time and the back pain is minimal. I feel like I have the tools to manage this myself now."
Pain: 0-1/10 at rest, 2/10 with prolonged activity. No pain with normal work duties or ADLs. Denies any radicular symptoms or neurological changes.
Function: Returned to full duty work 2 weeks ago without restrictions. Performing all ADLs without limitations. Exercising independently 4-5x/week. Successfully applied proper lifting mechanics during work tasks.
Objective Findings at Discharge:
Range of Motion (goniometric):
Discharge Initial Normal
Flexion 88° 30° 90°
Extension 28° 10° 30°
Side-bend R 30° 15° 30°
Side-bend L 30° 15° 30°
Strength (MMT):
Discharge Initial
Core 5/5 3/5
Hip flexors 5/5 4/5
Hip extensors 5/5 4-/5
QL bilaterally 5/5 3+/5
Functional Tests:
- Trunk stability: Plank hold 90 seconds (initially 20 seconds)
- Sit-to-stand: 20 repetitions in 30 seconds with good form
- Proper squat mechanics: 25 repetitions with 20 lbs, neutral spine maintained
- Lifting simulation (proper deadlift): 40 lbs with excellent form
Outcome Measures:
Discharge Initial Change MCID*
Oswestry Disability Index 8% 52% -44% 10%
Functional Rating Index 12% 68% -56% 9 points
Numeric Pain Rating 1/10 7/10 -6
Global Rating of Change +6 (good deal better)
*MCID = Minimal Clinically Important Difference (threshold for meaningful change)
GOALS STATUS
------------
Short-Term Goals (all goals MET):
✓ Decrease pain to 3/10 or less with ADLs
✓ Increase lumbar flexion ROM to 70°
✓ Improve core strength to 4+/5
✓ Independent with HEP
✓ Return to work with modified duty
Long-Term Goals (all goals MET):
✓ Pain 0-2/10 with all activities including work
✓ Restore full lumbar ROM (within normal limits)
✓ Core strength 5/5
✓ Return to full duty work without restrictions
✓ ODI score <20% (minimal disability)
✓ Independent with self-management program
DISCHARGE ASSESSMENT
--------------------
Patient successfully achieved all therapy goals and demonstrated excellent progress over 8 treatment sessions. ROM improved to within normal limits, strength normalized, and pain decreased from severe (7/10) to minimal (1/10). Functional outcome measures showed clinically significant improvements exceeding minimal important differences.
Patient demonstrated excellent adherence to HEP and successfully applied body mechanics training to work environment. Patient is independent with self-management strategies including appropriate exercise progression, pain management techniques, and activity modification as needed.
No remaining barriers to function. Patient returns to prior level of function at work and home. Patient educated on signs/symptoms requiring return to PT or MD evaluation (radicular symptoms, progressive weakness, loss of bowel/bladder control).
Functional Status: Patient has returned to full duty work as warehouse supervisor performing all lifting, bending, and physical demands without restrictions. All ADLs performed independently without pain or limitation.
Prognosis for Long-Term Outcome: Excellent. Patient has demonstrated ability to self-manage condition and possesses knowledge and skills to prevent recurrence.
DISCHARGE PLAN
--------------
Recommendations:
1. Continue independent HEP 3-4x/week for maintenance
2. Continue to apply proper body mechanics with all lifting tasks
3. Maintain physical activity and general fitness
4. Self-manage any minor flare-ups with ice/heat, modified activity, and HEP
Follow-Up: Patient discharged from PT at this time. Patient instructed to contact PT or MD if symptoms worsen or new symptoms develop.
Return to PT: Patient may return to PT if needed in the future. No current barriers to discharge from skilled PT services.
Patient Education Provided:
- Comprehensive HEP with written instructions and photos
- Red flags requiring medical attention
- Self-management strategies for minor symptom flare-ups
- Long-term prevention strategies
- Body mechanics guide specific to work tasks
Patient Verbalized Understanding: Patient demonstrated excellent understanding of discharge plan, HEP, and self-management strategies. Patient expressed confidence in ability to manage independently.
Reason for Discharge: Patient achieved all therapy goals. No longer requires skilled physical therapy intervention. Patient independent with self-management program.
___________________________
Physical Therapist Signature
Lic #: PT345678
Date: 03/15/2025PT Measurements & Terminology
Proper measurement and documentation techniques are essential for demonstrating objective progress and justifying skilled services.
Range of Motion (ROM)
Goniometric measurements in degrees
Measurement Methods:
Documentation Best Practices:
- Always measure and document bilaterally for comparison
- Note if active (AROM) or passive (PROM) motion
- Document end-feel (normal, hard, soft, empty)
- Record pain during motion and at what degree
- Compare to normative values and uninvolved side
Muscle Strength (MMT)
Manual Muscle Testing grading scale
MMT Grading Scale:
Plus/Minus Notation:
+: Stronger than grade but not next level (e.g., 4+/5)
-: Weaker than grade but not previous level (e.g., 4-/5)
Pain Scales
Standardized pain measurement tools
Quick, validated, widely understood
More sensitive to change than NRS
Captures pain distribution and patterns
Comprehensive pain characterization
Document pain at rest, with activity, and best/worst in 24 hours. Use OPQRST format.
Functional Outcome Measures
Standardized questionnaires and performance tests
Medicare Documentation Requirements
Medicare has specific documentation standards that physical therapists must meet to ensure reimbursement and avoid audits. Understanding these requirements is critical for practice success.
Medical Necessity
Document why skilled PT services are required
Must Include:
- Complexity requiring clinical judgment of a PT
- Skilled techniques not taught to patient/caregiver
- Need for ongoing assessment and modification
- Risk factors requiring skilled supervision
Example:
Patient requires skilled manual therapy for joint mobilization and skilled exercise prescription with progressive modification based on patient response. Home exercise program alone insufficient due to need for hands-on techniques and ongoing assessment of healing post-operatively.
Certifications and Recertifications
Initial certification at SOC, recertify every 90 days
Must Include:
- Start of care (initial evaluation) certification
- Recertification at 90 days if continuing
- Physician signature on plan of care
- Update to show continued need for skilled services
Example:
Plan of care certified by Dr. Smith on 02/15/2025 for frequency of 2x/week for 8 weeks. Recertification required by 05/15/2025 if patient not discharged.
Progress Documentation
Document objective progress toward functional goals
Must Include:
- Comparison to previous measurements
- Percentage toward goal achievement
- Functional improvements (not just impairment changes)
- Response to treatment interventions
- Updated prognosis and timeframe
Example:
ROM flexion improved from 105° to 118° (87% toward goal of 135°). LEFS score improved from 42/80 to 56/80, exceeding MCID of 9 points. Patient now independent with ADLs (goal met). Prognosis remains good for return to sport at 6 months.
Skilled Language
Use language that demonstrates skilled services
Avoid:
- Maintenance therapy
- General fitness/conditioning
- Routine or repetitive treatment
- Activities patient could do independently
Use Skilled Language:
- Progressive therapeutic exercise with skilled modification
- Neuromuscular re-education requiring clinical judgment
- Manual therapy techniques requiring skilled hands-on treatment
- Gait training with skilled assessment and cueing
Example:
Discharge Planning
Document discharge planning throughout episode of care
Must Include:
- Target discharge date or visit count
- Discharge criteria
- Progress toward independent self-management
- Plan for long-term maintenance
Example:
Patient expected to discharge in 3-4 weeks upon achieving full ROM and independent HEP. Currently 75% toward discharge criteria. Discharge planning includes advanced HEP, return to sport progression, and self-management strategies.
Common Audit Triggers
Medicare audits often focus on these documentation issues:
- •Lack of medical necessity or skilled service justification
- •Missing physician certification or signature
- •No objective progress documented over time
- •Maintenance therapy without documented change in functional status
- •Duplicate or copy-paste notes without individualized content
Common PT Documentation Mistakes
These frequent errors can lead to denied claims, audit failures, and legal liability. Learn what to avoid and how to document correctly.
Using vague, non-measurable language
Avoid:
Patient's shoulder is getting better. ROM improving.
Better:
Shoulder flexion ROM increased from 142° to 165° (23° improvement). Pain decreased from 7/10 to 3/10 with overhead reaching.
Why it matters: Medicare and insurance require objective, measurable data to justify continued skilled services and demonstrate medical necessity.
Not documenting functional outcomes
Avoid:
Strength increased to 4/5. Patient able to lift 10 lbs.
Better:
Quadriceps strength increased from 3+/5 to 4/5. Patient now able to ascend stairs step-over-step without pain (previously step-to pattern). LEFS score improved from 42 to 56 (exceeds MCID).
Why it matters: Functional outcomes demonstrate real-world impact and medical necessity. Impairment measures alone don't justify skilled services.
Copying previous notes without updates
Avoid:
Same HEP as last visit. Continue current treatment plan.
Better:
HEP progressed today: Increased resistance band from red to green for external rotation exercises (2x15). Added step-downs to HEP now that patient demonstrates eccentric quad control. Patient independent with new exercises.
Why it matters: Documentation must show skilled progression. Copy-paste suggests maintenance therapy not requiring skilled services.
Failing to justify continued skilled services
Avoid:
Continue current POC. Patient making progress.
Better:
Patient requires continued skilled PT for progressive joint mobilization techniques (Grade IV), which cannot be self-administered, and skilled modification of exercise program based on tissue healing and patient response. Exercise progression requires ongoing clinical judgment due to post-surgical precautions.
Why it matters: Must clearly articulate why PT intervention is necessary and cannot be done independently or by non-skilled personnel.
Not documenting response to treatment
Avoid:
Performed joint mobilization and therapeutic exercises.
Better:
Grade III posterior glide glenohumeral joint performed x3 minutes. Immediate reassessment showed ER ROM increased from 52° to 60° (8° improvement). Patient tolerated well with no increase in pain. Will continue this intervention next session.
Why it matters: Response to treatment justifies intervention choice and demonstrates skilled assessment informing clinical decisions.
Missing bilateral comparisons
Avoid:
Right knee flexion 115°.
Better:
Right knee flexion 115° (left knee 140°). Deficit of 25° compared to uninvolved side. Normal values 130-145°.
Why it matters: Bilateral comparison provides context for deficits and demonstrates medical necessity. Comparing to uninvolved side and norms is standard of care.
Inadequate initial evaluation
Avoid:
Patient has knee pain. ROM limited. Will work on strengthening.
Better:
Patient presents with anterior knee pain, insidious onset 6 weeks ago. Goniometric ROM: flexion 118° (N=135°), extension -5° (N=0°). MMT: quads 3+/5, hamstrings 4/5. Patellar mobility restricted medially. + patellar compression test. LEFS 42/80. Diagnosis: Patellofemoral pain syndrome with quad weakness and patellar hypomobility.
Why it matters: Initial evaluation must comprehensively document baseline to justify skilled services and establish medical necessity. Detailed assessment supports differential diagnosis.
Not using standardized outcome measures
Avoid:
Patient says shoulder is much better.
Better:
DASH score improved from 52 to 28 (24-point improvement, exceeds MCID of 10). Patient reports "shoulder is much better." Objective improvement demonstrated in functional questionnaire.
Why it matters: Standardized outcome measures provide validated, objective evidence of progress. Required by many payers and quality reporting programs.
Physical Therapy Note Template
Use this comprehensive SOAP template for initial evaluations and progress notes. Customize based on your setting and patient population.
PHYSICAL THERAPY SOAP NOTE TEMPLATE
===================================
Date: [Date] Time: [Time]
Patient: [Name] DOB: [DOB] ([Age] yo)
Diagnosis: [ICD-10 codes and diagnoses]
Physician: [MD name] Rx Date: [Date]
Visit #: [X of Y authorized]
SUBJECTIVE
----------
Chief Complaint: "[Patient's words]"
Pain Assessment:
- Location:
- Quality: (sharp, dull, aching, burning, stabbing)
- Intensity: __/10 at rest, __/10 with activity
- Aggravating factors:
- Alleviating factors:
- 24-hour pattern:
Functional Limitations:
- Work:
- ADLs:
- Recreation:
- Sleep:
Patient Goals:
1.
2.
3.
Prior Treatment:
Medical History:
Medications:
OBJECTIVE
---------
Observation:
- Posture:
- Gait:
- Assistive devices:
- Edema/swelling:
Palpation:
- Tenderness:
- Muscle tone:
- Temperature:
Range of Motion (goniometric, degrees):
Active Passive WNL Uninvolved
Motion 1: ___° ___° ___° ___°
Motion 2: ___° ___° ___° ___°
Manual Muscle Testing (0-5 scale):
Right Left
Muscle 1: __/5 __/5
Muscle 2: __/5 __/5
Special Tests:
- Test 1: [Positive/Negative]
- Test 2: [Positive/Negative]
Neurological Screening:
- Sensation:
- Reflexes:
- Coordination:
Functional Tests:
- Test 1:
- Test 2:
Outcome Measures:
- [LEFS/DASH/ODI/etc]: ____ (Date: ____)
Treatment Provided:
1.
2.
3.
Patient Response:
ASSESSMENT
----------
PT Diagnosis:
Impairments (Body Structure/Function):
-
-
Activity Limitations:
-
-
Participation Restrictions:
-
-
Progress Toward Goals:
1. Goal 1: ___% achieved
2. Goal 2: ___% achieved
Response to Treatment:
Prognosis:
Rehabilitation Potential:
Medical Necessity Justification:
PLAN
----
Frequency/Duration: __x/week for __ weeks (__visits total)
Interventions:
1. Manual therapy:
2. Therapeutic exercise:
3. Neuromuscular re-education:
4. Modalities:
5. Patient education:
Home Exercise Program:
-
-
Short-Term Goals (__ weeks):
1.
2.
3.
Long-Term Goals (__ weeks):
1.
2.
3.
Progression Plan:
Next Visit:
Medical Necessity:
_______________________________
Physical Therapist Signature
License #: PT______
Date: ___________Save Hours on PT Documentation with AI
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Try PatientNotes FreeFrequently Asked Questions
What should be included in a physical therapy SOAP note?
A PT SOAP note should include: Subjective (patient-reported pain, functional limitations, goals), Objective (ROM measurements, strength testing, special tests, functional assessments, standardized outcome measures), Assessment (PT diagnosis, progress toward goals, response to treatment, prognosis), and Plan (frequency/duration, specific interventions, exercise prescription, progression criteria, and discharge planning).
How do you document range of motion in physical therapy?
ROM should be documented using goniometric measurements in degrees. Include: the specific joint and motion, numerical measurement, whether active or passive, comparison to uninvolved side, comparison to normative values, end-feel quality, and any pain during motion. Example: "Right shoulder flexion: 142° AROM (left 175°, normal 180°), firm end-feel, pain 6/10 at end range."
What are the Medicare documentation requirements for physical therapy?
Medicare requires: certification/recertification of plan of care every 90 days with physician signature, documentation of medical necessity (why skilled PT is required), objective measurable progress toward functional goals, skilled language demonstrating clinical judgment, standardized outcome measures, and clear discharge planning. Progress notes must show comparison to baseline and percentage toward goals.
How often should physical therapists write progress notes?
Progress note frequency depends on payer requirements and clinical changes. Medicare requires documentation at minimum every 10 treatment days. Many facilities require weekly progress notes. Always document when there is significant change in patient status, major progression/regression, or at certification/recertification periods. Daily visit notes should capture treatment provided and response.
What functional outcome measures should PT use?
Common standardized outcome measures include: Lower Extremity Functional Scale (LEFS) for lower extremity conditions, Quick DASH for upper extremity, Oswestry Disability Index (ODI) for low back pain, Neck Disability Index (NDI) for neck pain, Patient-Specific Functional Scale (PSFS) for any condition, and condition-specific measures like IKDC for knee injuries. FOTO may be required by some payers. Select measures validated for the specific condition and track throughout episode of care.
How do you document skilled services in physical therapy?
Use skilled language emphasizing clinical judgment: "progressive therapeutic exercise with skilled modification based on patient response," "manual therapy techniques requiring specialized training," "neuromuscular re-education with skilled cueing," "gait training with skilled assessment." Avoid maintenance language like "routine exercises" or "continued same program." Document why the service requires PT expertise and cannot be done independently or by non-skilled personnel.
What is the difference between PT initial evaluation and progress notes?
Initial evaluations are comprehensive baseline assessments including full history, detailed examination, diagnosis, prognosis, and complete plan of care with goals. They establish medical necessity and justify frequency/duration. Progress notes are briefer, focused updates documenting changes since previous note, response to treatment, progress toward goals (with percentages), and plan updates. Progress notes demonstrate ongoing medical necessity for skilled services.
How should physical therapists document pain in SOAP notes?
Document pain comprehensively using: numeric rating scale (0-10), location with body diagram if needed, quality (sharp, dull, aching, burning), timing (constant vs intermittent, 24-hour pattern), aggravating factors, alleviating factors, and functional impact. Use the OPQRST method: Onset, Provocation, Quality, Region/Radiation, Severity, Timing. Compare pain levels at rest vs with activity. Track changes from visit to visit.
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