Hip Fracture SOAP Note Examples

Complete documentation templates for ORIF, hip replacement, and hemiarthroplasty across SNF, acute care, and home health settings.

Hip Fracture Documentation Overview

Hip fractures are among the most common orthopedic injuries requiring rehabilitation documentation. Whether your patient underwent an open reduction internal fixation (ORIF), total hip replacement (THR), or hemiarthroplasty, thorough documentation is essential for demonstrating medical necessity, tracking progress, and ensuring continuity of care.

Hip fracture rehabilitation typically spans multiple care settings:

  • Acute Care: Initial post-operative mobilization and education (1-5 days)
  • Skilled Nursing Facility (SNF): Intensive rehabilitation phase (1-4 weeks)
  • Home Health: Transition to community mobility and independence (2-8 weeks)
  • Outpatient: Advanced strengthening and return to prior level of function
Documentation Tip

Always document the specific surgical procedure (ORIF, THR, hemiarthroplasty), the surgical approach (posterior, anterior, lateral), and any weight-bearing or movement precautions ordered by the surgeon.

Key Documentation Elements for Hip Fracture

Surgical Procedure Details

  • ORIF (Open Reduction Internal Fixation): Document hardware type (screws, plates, rods), fracture location (femoral neck, intertrochanteric, subtrochanteric)
  • Total Hip Replacement (THR): Note surgical approach, implant type, and specific precautions
  • Hemiarthroplasty: Document whether bipolar or unipolar, typically for elderly patients with displaced femoral neck fractures

Weight-Bearing Status

  • Non-weight bearing (NWB)
  • Toe-touch weight bearing (TTWB)
  • Partial weight bearing (PWB) - document percentage if specified
  • Weight bearing as tolerated (WBAT)
  • Full weight bearing (FWB)

Hip Precautions (Posterior Approach)

  • No hip flexion beyond 90 degrees
  • No hip adduction past midline
  • No internal rotation
  • Use of elevated toilet seat, hip kit, and proper transfer techniques

Functional Mobility Documentation

  • Bed mobility (supine to/from sit, rolling)
  • Transfers (sit to stand, bed to chair, toilet transfers)
  • Gait (assistive device, distance, assistance level)
  • Stairs (number of steps, rail use, assist level)

SNF SOAP Note Example - Hip Fracture s/p ORIF

Physical Therapy Daily Note - SNF Setting

Scenario: 78-year-old female, POD #5 s/p right ORIF for intertrochanteric hip fracture. WBAT RLE. Prior level of function: independent ambulation without device, living alone in single-story home.

S - Subjective

Patient reports "I'm feeling stronger today" and rates pain 4/10 at right hip with activity, improved from 6/10 yesterday. Patient denies dizziness or nausea. States she is motivated to return home and live independently. Reports sleeping better last night with fewer position changes needed for comfort.

O - Objective

Vital Signs: BP 128/78, HR 76, SpO2 97% on RA

Bed Mobility: Supine to sit with min A for LE management, improved from mod A. Rolling to bilateral sides with supervision.

Transfers: Sit to stand from mat (18") with min A x1 and front wheeled walker, improved from mod A. Bed to wheelchair with min A.

Gait: Ambulated 150 feet x2 with FWW, min A x1 for balance and verbal cues for weight shifting. Gait pattern improved with decreased trunk lean to right. WBAT RLE maintained throughout.

Therapeutic Exercise: Supine hip flexion AROM 0-85 degrees (limited by precaution awareness). Quad sets 3x10, SLR with assist 3x8. Ankle pumps 3x15 bilateral.

Balance: Static standing at parallel bars with supervision, dynamic standing reach with min A for safety.

A - Assessment

Patient is making good progress toward therapy goals. Demonstrates improved bed mobility, transfer ability, and gait distance compared to previous session. Decreased pain levels allowing for increased participation in therapy. Patient demonstrates good understanding of weight bearing status and hip precautions. Continued skilled PT services are medically necessary to address impairments in strength, balance, and functional mobility to enable safe discharge to home.

P - Plan

Continue PT 5x/week for progressive gait training, transfer training, therapeutic exercise for RLE strengthening, and balance activities. Progress to least restrictive assistive device as strength and balance improve. Initiate stair training when patient tolerates 200+ feet ambulation with SBA. Coordinate with OT for ADL training and home safety assessment. Anticipated discharge to home with home health services in 7-10 days pending achievement of safe, supervised ambulation with appropriate device.

Acute Care SOAP Note Example - Total Hip Replacement

Physical Therapy Evaluation - Acute Care Setting

Scenario: 65-year-old male, POD #1 s/p left total hip arthroplasty via posterior approach for displaced femoral neck fracture after fall. Posterior hip precautions in effect. WBAT LLE.

S - Subjective

Patient reports "I'm ready to get moving" though notes moderate pain at surgical site. Rates pain 5/10 at rest, 7/10 with movement. PTA pain medication administered 30 minutes ago. Patient lives with spouse in two-story home, bedroom upstairs. Prior level: independent ambulation, works as accountant (sedentary), golfs on weekends. Patient states understanding of posterior hip precautions as explained by nursing and surgical team.

O - Objective

Vital Signs Pre-Treatment: BP 142/88, HR 84, SpO2 96% on 2L NC
Vital Signs Post-Treatment: BP 138/82, HR 92, SpO2 95% on 2L NC

Incision: Posterior lateral approach, dressing clean/dry/intact. Hemovac drain in place.

Bed Mobility: Supine to sit with mod A x1 for LE management, verbal cues for hip precaution compliance. Log roll to right side with min A.

Transfers: Sit to stand from edge of bed with mod A x1, front wheeled walker. Required tactile cues for weight shifting through LLE.

Gait: Ambulated 25 feet in room with FWW, mod A x1 for balance and gait pattern. Gait slow and guarded, decreased stance time on LLE. Patient required rest break due to fatigue and pain increase to 8/10. WBAT maintained.

Posterior Hip Precautions: Patient educated on no flexion >90 degrees, no adduction past midline, no internal rotation. Demonstrated understanding with return demonstration during bed mobility.

A - Assessment

Patient is POD #1 following left THA via posterior approach for femoral neck fracture. Demonstrates impaired functional mobility requiring mod A for all transfers and gait. Pain and post-operative fatigue limiting activity tolerance. Patient demonstrates good cognitive ability and motivation for recovery. Rehabilitation potential is good given prior functional level, patient motivation, and supportive home environment. Skilled PT intervention is necessary to progress mobility, ensure hip precaution compliance, and prepare patient for safe transition to next level of care.

P - Plan

Continue PT 1-2x daily for gait training, transfer training, therapeutic exercise, and patient/family education on hip precautions and home safety. Goals for discharge: ambulate 150+ feet with assistive device and supervision, transfers with min A or less, demonstrate independence with hip precaution compliance. Recommend discharge to SNF for continued intensive rehabilitation given mod A level and two-story home. Coordinate with case management for discharge planning. Will reassess tomorrow for progress and update recommendations.

Home Health SOAP Note Example - Hip Replacement

Physical Therapy Visit Note - Home Health Setting

Scenario: 72-year-old female, 3 weeks s/p right total hip arthroplasty via anterior approach for osteoarthritis, now discharged home from SNF. No hip precautions per surgeon (anterior approach). FWB RLE. Lives with daughter in single-level home.

S - Subjective

Patient reports "I'm so happy to be home" and notes right hip soreness rated 3/10, well-controlled with Tylenol as needed. States she is walking more around the house each day and practiced exercises "every day like you told me." Patient reports one near-fall episode when reaching for cabinet but caught herself on counter. No actual falls. Daughter present and reports patient is doing well but "still needs reminders to use her walker."

O - Objective

Vital Signs: BP 124/76, HR 72, SpO2 98% on RA

Home Environment: Single-level home, 2 steps to enter with bilateral rails. Clear pathways, adequate lighting. Bathroom has grab bars at toilet and tub.

Transfers: Sit to stand from standard chair with SBA and single point cane, improved from min A with FWW at SNF discharge. Toilet transfer with grab bar use, supervision for safety.

Gait: Ambulated 200 feet throughout home with single point cane, SBA for safety and verbal cues for upright posture. Gait pattern normalized, good weight acceptance through RLE. Demonstrated outdoor ambulation on driveway 100 feet with SBA.

Stairs: Ascended/descended 2 entry steps with bilateral rail and SBA, step-to pattern. Patient demonstrated proper technique (up with strong, down with weak).

Therapeutic Exercise: Reviewed and progressed HEP. Standing hip abduction 3x12 with counter support. Mini squats 3x10. Heel raises 3x15. TheraBand hip extension 3x10 yellow resistance. Single leg stance 3x15 seconds each with counter support.

Balance: Romberg stance 30 seconds eyes open, 20 seconds eyes closed. Tandem stance 15 seconds with UE support. Single leg stance R 12 seconds, L 18 seconds.

A - Assessment

Patient demonstrates continued improvement in functional mobility and is progressing well in the home environment. Successfully transitioned from FWW to single point cane with supervision. Balance and strength improving as evidenced by improved single leg stance times and ability to perform standing exercises without loss of balance. Near-fall incident indicates continued fall risk requiring skilled intervention for balance training and safety education. Patient motivated and compliant with HEP. Skilled PT services remain necessary to progress balance, community ambulation, and reduce fall risk for safe independence.

P - Plan

Continue home health PT 2x/week for 3 weeks. Focus on progressive balance training, community ambulation, and fall prevention strategies. Progress HEP to include more challenging balance activities. Goal: independent ambulation with cane, independent home and community mobility, BBS score >45/56 indicating low fall risk. Educate patient/daughter on fall prevention strategies including consistent cane use during transitional movements and reaching tasks. Consider discharge to outpatient PT for continued strengthening and return to recreational activities (patient interested in returning to water aerobics).

Documenting Hip Precautions

Accurate documentation of hip precautions is critical for patient safety and care coordination. The specific precautions depend on the surgical approach used.

Posterior Approach Precautions

The posterior (or posterolateral) approach is the most common surgical approach for hip replacement. Document the following precautions:

  • No hip flexion beyond 90 degrees
  • No hip adduction past midline (no crossing legs)
  • No internal rotation of the hip
  • Duration: typically 6-12 weeks post-op, per surgeon protocol

Anterior Approach Precautions

The anterior approach often has fewer or no precautions, but always verify with the surgical team:

  • May have no specific movement restrictions
  • Some surgeons limit hip extension and external rotation initially
  • Always document surgeon-specific orders

Lateral Approach Precautions

The lateral (or direct lateral) approach may include:

  • No hip adduction past midline
  • Limit active hip abduction initially (protect gluteus medius repair)
  • No external rotation past neutral
Important

Always verify precautions with the surgical report and orders. Precaution protocols vary by surgeon and can change based on intraoperative findings. Document the specific precautions in effect for your patient.

Progress Indicators for Hip Fracture Rehabilitation

Documenting measurable progress is essential for demonstrating medical necessity. Include these objective measures in your notes:

Functional Mobility Measures

  • Gait Distance: Track feet/meters ambulated per session
  • Assistance Levels: Document changes from dependent to max A to mod A to min A to SBA to supervision to modified independent to independent
  • Assistive Device Progression: Walker to cane to no device
  • Gait Speed: 10-meter walk test or timed walks

Standardized Outcome Measures

  • Timed Up and Go (TUG): Baseline and discharge scores (>12 seconds indicates fall risk)
  • Berg Balance Scale (BBS): Score out of 56 (<45 indicates fall risk)
  • 5x Sit to Stand: Functional lower extremity strength
  • LEFS (Lower Extremity Functional Scale): Patient-reported outcomes
  • Harris Hip Score: Hip-specific function and pain measure

Strength and ROM Documentation

  • Hip AROM/PROM: Flexion, abduction, extension (within precaution limits)
  • MMT: Hip flexors, extensors, abductors, knee extensors
  • Functional Strength: Ability to perform SLR, bridge, single leg stance

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