SOAP Note

SOAP notes are a standardized method clinicians use to document patient encounters. Each section serves a specific purpose:

• Subjective: Captures the patient’s reported symptoms and concerns.
• Objective: Includes measurable findings such as range of motion, strength, or test results.
• Assessment: Reflects the clinician’s professional judgment and diagnosis.
• Plan: Outlines the next steps in care.

In physical therapy, occupational therapy, and chiropractic practices, SOAP notes support consistency, compliance, and continuity of care. Digital SOAP notes within an EMR reduce handwriting errors and make documentation easier to review during audits.

Why it matters:

SOAP notes help protect clinics during audits, support accurate billing, and ensure clinical decisions are clearly documented for medical necessity.

Prompt’s Take / Pro Tip:

There’s no trophy for documenting at home. The best SOAP note workflows balance structure with flexibility. Overly rigid templates slow clinicians down, while unstructured notes risk compliance issues.

FAQ

• Are SOAP notes required for billing? Most payers expect documentation that follows a SOAP-style structure to justify billing, even if templates vary.
• Can SOAP notes be customized? Yes. Many clinics adapt templates to match specialty needs (like Pelvic Health or Vestibular) and payer requirements.
• How often do I need to write a SOAP note? A note is generally required for every patient visit (encounter) to justify the billing for that date of service.‍
• Can AI write my SOAP notes? AI can assist by summarizing inputs or transcribing sessions, but the clinician is always responsible for the accuracy and clinical judgment within the note.