Total Knee Replacement SOAP Notes for Physical Therapy
Complete documentation guide for TKR/TKA rehabilitation. SOAP note examples for acute, subacute, and outpatient phases with goals, interventions, and outcome measures.
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TKR Physical Therapy Documentation Overview
Total knee replacement (TKR), also called total knee arthroplasty (TKA), is one of the most common orthopedic surgeries. Effective PT documentation must capture the patient's progress through distinct recovery phases, each with different goals, precautions, and functional expectations.
Your TKR SOAP notes should always include: ROM measurements (especially flexion/extension), weight-bearing status, pain levels, edema assessment, gait pattern, and functional mobility status. These elements demonstrate skilled need and track meaningful progress.
Recovery Phases and Settings
- Acute Phase (Days 1-7): Inpatient hospital or acute rehab. Focus on early mobilization, edema management, and basic transfers.
- Subacute Phase (Weeks 2-6): Skilled nursing, home health, or outpatient. Progressive ROM, strengthening, and gait training.
- Outpatient Phase (Weeks 6-12+): Outpatient clinic. Advanced strengthening, functional training, and return to activities.
Acute Phase SOAP Note Example (Days 1-7)
In the acute phase, documentation focuses on early mobilization, pain management, edema control, and establishing baseline measurements. Patients typically have weight-bearing restrictions and require maximum assistance.
TKR Acute Phase Daily Note - Post-Op Day 2
Scenario: 72-year-old female, post-op day 2 following left total knee arthroplasty for end-stage osteoarthritis. First PT session post-surgery.
S - Subjective
O - Objective
Incision: Clean, dry, intact with staples. Moderate ecchymosis surrounding knee.
Edema: 3+ pitting edema L knee and distal LE.
ROM: L knee flexion 45 degrees PROM (limited by pain and swelling), extension -10 degrees.
Strength: L quad lag present, unable to perform SLR. L hip flexion 3/5, hip abduction 3/5.
Functional Mobility: Supine to sit with max A x1. Sit to stand with max A x1 using front-wheeled walker. Ambulated 25 feet x1 with FWW, max A x1 for balance and cueing, WBAT per surgeon.
Treatment: PROM L knee flexion/extension, ankle pumps, quad sets with verbal and tactile cueing, gluteal sets, edge of bed exercises, gait training with FWW.
Education: Reviewed weight-bearing precautions, use of walker, importance of ice and elevation, ankle pumps for DVT prevention.
A - Assessment
P - Plan
This acute phase TKR SOAP note example demonstrates documentation of early post-operative status with appropriate objective measures and skilled interventions.
Subacute Phase SOAP Note Example (Weeks 2-6)
The subacute phase focuses on progressive ROM gains (targeting 110+ degrees flexion), quad strengthening to eliminate lag, gait normalization, and functional independence. Documentation should show measurable week-over-week progress.
TKR Subacute Phase Daily Note - Post-Op Week 3
Scenario: 68-year-old male, post-op week 3 following right TKA. Home health PT visit. Patient progressing well with ROM but struggling with quad strength.
S - Subjective
O - Objective
Incision: Staples removed, incision well-healed, no signs of infection.
ROM: R knee flexion 98 degrees AROM (from 85 degrees last visit), extension -3 degrees (from -5 degrees).
Strength: R quad 3+/5 with minimal lag, SLR independent. R hip flexion 4/5, hip abduction 4/5, hamstrings 4/5.
Gait: Ambulating 300 feet with single point cane, supervision for safety. Decreased antalgic pattern. Mild Trendelenburg noted on R stance phase.
Functional Mobility: Bed mobility independent. Supine to sit independent. Sit to stand with SPC, modified independent. Ascends/descends 4 steps with rail and SPC, min A x1.
Treatment: Stationary bike x 10 min (increasing ROM on pedal stroke), AAROM/AROM knee flexion in sitting, heel slides, quad sets, SLR (4 directions), mini squats at counter, step-ups 4" step, gait training with cane focusing on heel strike and knee extension in stance.
HEP Review: Reviewed and progressed HEP. Added resistance band exercises. Patient demonstrates all exercises with correct form.
A - Assessment
P - Plan
Outpatient Phase SOAP Note Example (Weeks 6-12+)
Outpatient phase documentation emphasizes functional gains, return to activities, and discharge planning. Patients should be approaching terminal ROM, with focus shifting to strength, endurance, and higher-level activities.
TKR Outpatient Phase Progress Note - Post-Op Week 8
Scenario: 65-year-old female, post-op week 8 following left TKA. Outpatient PT visit. Patient goals include returning to golf and gardening.
S - Subjective
O - Objective
ROM: L knee flexion 118 degrees AROM, extension 0 degrees (full).
Strength: L quad 4/5, hamstrings 4+/5, hip flexion 4+/5, hip abduction 4/5. Able to perform single leg squat to 45 degrees with good control.
Gait: Ambulating without assistive device, normal heel-toe pattern, no observable gait deviations. Able to walk backwards and sidestepping without difficulty.
Functional Tests: TUG: 9.2 seconds (from 12.5 seconds at initial outpatient eval). 30-second sit-to-stand: 14 reps (from 9 reps). Single leg stance: 25 seconds eyes open (from 12 seconds).
Treatment: Bike x 15 min warm-up, leg press 60 lbs x 3x12, step-ups 8" step with 5 lb weights, Romanian deadlifts, lateral band walks, single leg balance activities on foam, mini golf swing simulation movements, functional reaching and squatting for gardening simulation.
Outcome Measure: LEFS score: 58/80 (from 42/80 at initial outpatient eval).
A - Assessment
P - Plan
Common TKR Physical Therapy Goals
Well-written goals are specific, measurable, and phase-appropriate. Here are examples for each phase of TKR rehabilitation:
Acute Phase Goals (Days 1-7)
- Patient will achieve knee flexion of 90 degrees PROM within 5-7 days for functional sitting and transfers.
- Patient will perform supine to sit transfer with modified independence within 3 days for safe bed mobility.
- Patient will ambulate 150 feet with appropriate assistive device and supervision within 5 days for discharge readiness.
- Patient will demonstrate independent quad sets and ankle pumps within 2 days for early muscle activation and DVT prevention.
- Patient will achieve knee extension within 5 degrees of full within 7 days to prevent flexion contracture.
Subacute Phase Goals (Weeks 2-6)
- Patient will achieve knee flexion of 110 degrees AROM within 4 weeks for functional stair climbing and sitting tolerance.
- Patient will ambulate 500 feet with least restrictive device independently within 4 weeks for community ambulation.
- Patient will ascend/descend 12 stairs with rail independently within 4 weeks for safe home navigation.
- Patient will demonstrate 4/5 quad strength with no extensor lag within 6 weeks for normalized gait pattern.
- Patient will perform sit to stand from standard height chair independently within 3 weeks for functional transfers.
Outpatient Phase Goals (Weeks 6-12+)
- Patient will achieve knee flexion of 120+ degrees AROM within 10 weeks for full functional ROM.
- Patient will demonstrate TUG score of less than 8 seconds within 10 weeks indicating low fall risk.
- Patient will complete 30-second sit-to-stand with 15+ repetitions within 12 weeks for functional lower extremity strength.
- Patient will return to golf/tennis/recreational activities with proper mechanics within 12 weeks for return to prior level of function.
- Patient will achieve LEFS score of 65/80 or greater within 12 weeks indicating high functional status.
Typical TKR Interventions by Phase
Acute Phase (Days 1-7)
- PROM/AAROM knee flexion/extension
- Ankle pumps for DVT prevention
- Quad sets, gluteal sets
- Bed mobility training
- Transfer training (supine to sit, sit to stand)
- Gait training with walker
- Cryotherapy and elevation
- Patient/family education
Subacute Phase (Weeks 2-6)
- AROM exercises (heel slides, seated knee extension)
- Stationary bike for ROM
- SLR (4 directions)
- Mini squats, step-ups
- Gait training with cane progression
- Stair training
- Balance activities
- Scar mobilization
Outpatient Phase (Weeks 6-12+)
- Progressive resistance training (leg press, squats)
- Single leg exercises
- Proprioception/balance training
- Functional training (reaching, lifting)
- Sport-specific drills
- Plyometrics (as appropriate)
- Endurance training
- Return to activity training
Outcome Measures for TKR Documentation
Using standardized outcome measures strengthens your documentation and demonstrates skilled need. Here are the most commonly used measures for TKR rehabilitation:
| Measure | What It Assesses | When to Use | MCID |
|---|---|---|---|
| Timed Up and Go (TUG) | Mobility, fall risk, functional gait | All phases; every 2-4 weeks | 2.5 seconds |
| 30-Second Sit-to-Stand | Lower extremity strength, endurance | Subacute and outpatient phases | 2-3 reps |
| LEFS (Lower Extremity Functional Scale) | Self-reported function | Initial eval, discharge, every 4 weeks | 9 points |
| KOOS (Knee Osteoarthritis Outcome Score) | Pain, symptoms, ADL, sport, QOL | Initial eval, discharge | 8-10 points |
| 6-Minute Walk Test | Functional endurance | Outpatient phase | 50 meters |
| Single Leg Stance | Balance, fall risk | Subacute and outpatient phases | N/A |
| Goniometry (ROM) | Knee flexion/extension | Every visit | 5-10 degrees |
MCID = Minimal Clinically Important Difference. When documenting progress, note when patients exceed the MCID to demonstrate meaningful improvement. For example: "TUG improved from 12.5 to 9.2 seconds, exceeding the MCID of 2.5 seconds."
TKR Documentation Tips
What Auditors Look For
- Objective measurements: Always include ROM in degrees, not "WNL" or "improved"
- Skilled interventions: Document why your treatment requires a licensed therapist
- Progress toward goals: Show measurable change between visits
- Functional relevance: Connect impairments to functional limitations
- Medical necessity: Document why continued therapy is needed
Common Documentation Mistakes to Avoid
Avoid These
- "ROM improving" (not measurable)
- "Patient tolerated treatment well" (vague)
- "Continue current plan" (no specifics)
- Copy-pasting notes between visits
- Missing weight-bearing status
Do This Instead
- "Knee flexion improved 85 to 98 degrees"
- "Completed full treatment with pain 4/10"
- "Progress resistance, add step-ups 6""
- Unique documentation each visit
- "WBAT per surgeon protocol"
Phrases That Demonstrate Skilled Need
- "Patient requires skilled PT for manual ROM techniques to address soft tissue restrictions limiting knee flexion..."
- "Neuromuscular re-education indicated to address persistent quad lag affecting gait mechanics..."
- "Skilled balance training necessary to address proprioceptive deficits and reduce fall risk..."
- "Therapeutic exercise with progression requires skilled PT supervision to ensure proper form and prevent compensation..."
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Try Free for 3 DaysTKR Documentation FAQ
How often should I document ROM for TKR patients?
Document knee ROM at every visit, especially in the acute and subacute phases when rapid changes are expected. Include both flexion and extension measurements. In the outpatient phase, once ROM goals are achieved, you can document less frequently (every 2-4 weeks) unless changes occur.
What ROM is considered "functional" for TKR?
Generally, 110-115 degrees of knee flexion is considered functional for most daily activities. 90 degrees is needed for basic sitting and car transfers. 105+ degrees is needed for stairs. Full extension (0 degrees) is important for normal gait. Most surgeons and therapy protocols aim for 120+ degrees by 12 weeks.
How do I document skilled need when a TKR patient is progressing well?
Focus on what the patient still cannot do independently and the skilled interventions required. Even if ROM is good, you may document skilled need for progressive strengthening, balance training, gait normalization, or sport-specific training. Use phrases like "skilled PT required to progress resistance training safely" or "skilled balance training to address fall risk."
Should I document the patient's home exercise program (HEP)?
Yes, always document HEP review and any modifications. Note patient compliance ("Patient reports completing HEP daily"), any exercises added or progressed, and demonstration of correct form. This shows ongoing education and supports skilled need for therapy supervision.
How do I document when a TKR patient plateaus?
Document the plateau objectively (e.g., "ROM unchanged at 105 degrees for 2 visits"), identify potential reasons (pain, swelling, soft tissue restrictions), describe skilled interventions to address the plateau (manual therapy, different exercise approaches), and modify goals if appropriate. If plateau persists, discuss with the physician and document the communication.