SOAP Note Examples: Complete Samples for Every Discipline

Patient reports "much better week" with decreased frequency of radiating symptoms. Current pain level 4/10 in lower back (was 7/10 at initial evaluation). Radiating pain into L leg occurring only with prolonged sitting >45 minutes, improved from constant symptoms previously. Patient states she completed HEP daily as instructed and has been walking 20 minutes each evening. Reports able to sit through most of work meetings now without needing to stand. Denies any new numbness, tingling, or weakness. Goals remain to return to full work duties and resume yoga class.

Functional Status: Able to perform all household tasks. Returned to driving 30+ minutes. Still avoiding bending to pick up items from floor.

Observation: Patient ambulates with normalized gait pattern, no antalgic posturing noted. Transfers sit-to-stand without upper extremity support.

Palpation: Decreased tenderness L paraspinals L4-S1 compared to last visit. Muscle guarding minimal.

AROM: Lumbar flexion 75% (was 50%), extension 80% (was 60%), bilateral sidebending WFL. All motions performed with improved quality and decreased hesitation.

Neurological: L4, L5, S1 dermatomal sensation intact bilaterally. DTRs 2+ bilateral patella and Achilles. Great toe extension 5/5 bilateral.

Special Tests: SLR negative bilaterally (was positive L at 45 degrees). Slump test negative. Prone instability test negative (was positive).

Functional Testing: Single leg stance 25 seconds bilateral (was 12 seconds L). Tandem stance 30 seconds without loss of balance.

Treatment Provided: Manual therapy: lumbar PA mobilizations grades III-IV L4-L5 x 5 minutes. Soft tissue mobilization bilateral QL and piriformis x 8 minutes. Therapeutic exercise: prone press-ups x 3 sets of 10, bridges with march x 2 sets of 10 each leg, bird dogs x 2 sets of 10 each side, standing hip hinge practice x 10 reps. Patient education: progression of HEP, reviewed return to yoga modifications. Total treatment time: 45 minutes.

Diagnosis: Lumbar radiculopathy L5 distribution, improving (ICD-10: M54.16)

Clinical Impression: Patient demonstrates significant improvement in all objective measures since initial evaluation. Resolution of positive neurodynamic tests and improved lumbar mobility indicate decreasing nerve root irritation. Improved single leg stance reflects enhanced motor control and confidence. Patient responding well to combination of manual therapy and stabilization exercise program. Centralization of symptoms and improved sitting tolerance suggest favorable prognosis for full recovery.

Progress Toward Goals:

• STG 1: Sit 45+ minutes without increased symptoms - ACHIEVED (able to sit through most work meetings)
• STG 2: Pain 4/10 or less with daily activities - ACHIEVED (currently 4/10)
• LTG 1: Full return to work duties - IN PROGRESS (90% complete, avoiding prolonged floor-level tasks)
• LTG 2: Return to yoga class - IN PROGRESS (will begin modified participation next week)

Skilled Need: Continued skilled physical therapy required for progression of manual therapy techniques, advancement of neuromuscular re-education, and supervised return to higher-level activities including yoga modifications.

Treatment Plan: Continue PT 2x/week for 2 more weeks, then reassess for reduction to 1x/week. Focus on progressive loading, return to bending activities, and yoga preparation.

Updated Goals:

• STG (2 weeks): Perform floor-level tasks (bending, kneeling) without symptom increase
• STG (2 weeks): Complete modified yoga class without flare-up
• LTG (4 weeks): Discharge with independent management and full return to all activities

HEP Update: Added standing hip hinge progression with light resistance, cat-cow stretches, and modified sun salutation sequence. Written and video instructions provided via patient portal. Patient demonstrated all exercises correctly.

Patient Education: Discussed gradual return to yoga - start with gentle/restorative class, avoid deep forward folds initially, use props as needed. Reviewed signs of symptom exacerbation that would warrant activity modification.

Next Visit: Thursday 1/30 at 10:00 AM. Will progress to deadlift pattern and higher-level balance activities.

Patient states "I think my arm is waking up a little." Reports noticing increased movement in L hand when reaching for water cup this morning. Wife present and confirms she observed patient spontaneously using L hand to stabilize newspaper while reading. Patient expresses frustration with continued difficulty buttoning shirt: "I used to get dressed in 5 minutes, now it takes forever." Motivated to continue therapy, states primary goal is to return home and be independent with self-care. Reports good sleep overnight, no pain, and feeling "stronger than yesterday."

Prior Level of Function: Independent with all ADLs and IADLs. Retired accountant, lives with wife in two-story home. Active in community, drives, manages finances.

UE Motor Status:

• L shoulder: Flexion 3+/5 (was 3/5), abduction 3/5, ER/IR 3/5
• L elbow: Flexion 4-/5 (was 3+/5), extension 3+/5
• L wrist: Flexion 3/5, extension 2+/5
• L hand: Grip 12 lbs (was 8 lbs), pinch 4 lbs (was 2 lbs)

Sensation: Light touch intact throughout L UE. Proprioception impaired at L wrist and fingers (3/5 correct responses).

Coordination: Finger-to-nose with mild dysmetria L. 9-hole peg test: 58 seconds L (was unable to complete), 16 seconds R.

Functional Performance:

• Upper body dressing: Mod A with button-up shirt using one-handed technique; total time 12 minutes (was 18 minutes)
• Lower body dressing: Min A for socks and shoes with use of reacher and sock aid
• Grooming: Mod I with set-up for shaving, brushing teeth; used L hand as stabilizer successfully
• Feeding: Mod I; able to use L hand to stabilize bowl while eating with R

Cognition: Alert, oriented x4. Attention adequate for 45-minute session with 1 verbal redirect. Problem-solving intact for ADL task modifications.

Treatment Provided:

• Therapeutic exercise L UE: PROM/AROM all joints x 10 minutes, grip strengthening with therapy putty x 5 minutes
• Fine motor training: Pegboard activities, coin manipulation, simulated buttoning x 15 minutes
• ADL training: Upper body dressing with compensatory strategies x 15 minutes
• Caregiver education: Reviewed home setup recommendations with wife x 5 minutes

Total treatment time: 50 minutes

Diagnosis: L CVA with R hemiparesis affecting UE function, ADL performance (ICD-10: I63.9, G81.11)

Clinical Interpretation: Patient is day 8 post L MCA CVA demonstrating encouraging motor recovery in L UE. Improved grip strength (8 to 12 lbs) and ability to complete 9-hole peg test (previously unable) indicate meaningful fine motor gains. Spontaneous use of L hand as stabilizer during functional tasks suggests improved motor planning and integration. Proprioceptive deficits continue to impact coordination but are compensated with visual feedback.

Functional Implications: Improved UE function translating to decreased assistance needs for dressing and grooming. Patient approaching modified independence for basic ADLs. Continued deficits in fine motor control limit independence with fasteners and small object manipulation.

Progress Toward Goals:

• STG 1: Complete upper body dressing with Min A - IN PROGRESS (currently Mod A, improving)
• STG 2: Bilateral hand use for stabilization tasks - ACHIEVED (using L hand to stabilize during meals, grooming)
• LTG: Modified independence with all basic ADLs - IN PROGRESS (on track for discharge goal)

Rehabilitation Potential: Good. Patient demonstrates motivation, family support, cognitive ability to learn compensatory strategies, and ongoing motor recovery. Expected to achieve modified independence with ADLs by discharge.

Treatment Plan: Continue OT daily x 50-60 minutes. Focus on progressive fine motor training, ADL skill development, and caregiver education for discharge preparation.

Short-Term Goals (1 week):

• Complete upper body dressing with Min A using button hook and one-handed techniques
• Complete 9-hole peg test L hand in under 45 seconds
• Grooming tasks with supervision only

Long-Term Goals (Discharge in ~2 weeks):

• Modified independence with all basic ADLs using adaptive equipment as needed
• Demonstrate safe one-handed techniques for all self-care tasks
• Caregiver independent with cueing strategies and safety supervision

Adaptive Equipment: Ordered button hook, elastic shoelaces, and built-up handle utensils. Will train patient and wife on use.

Discharge Planning: Home evaluation scheduled for 1/31. PT, OT, and case manager to attend. Will assess bathroom safety, bedroom setup, and kitchen accessibility.

Next Session: Tomorrow 9:00 AM. Will focus on lower body dressing and introduce kitchen task simulation.

Client states "I actually had a couple of good days this week." Reports successfully using grounding techniques during a panic episode at work on Tuesday - "I did the 5-4-3-2-1 thing and it helped me not leave the meeting." Rates overall anxiety as 5/10 for the week (was 7/10 at last session). Sleep improved to 6-7 hours most nights with sleep hygiene changes implemented.

Client discussed ongoing conflict with mother, stating "She called three times this week and I only answered once. I felt guilty but also relieved." Exploring boundaries in family relationships.

Reports medication compliance with Zoloft 50mg daily, no side effects. Denies suicidal ideation, homicidal ideation, or self-harm urges. Denied any alcohol or substance use this week.

Treatment Goals: Manage anxiety without panic attacks disrupting work; improve sleep to 7+ hours consistently; establish healthier boundaries with family.

Appearance: Appropriately dressed in business casual attire, well-groomed. No observable changes from previous sessions.

Behavior: Good eye contact maintained throughout session. Seated comfortably, minimal fidgeting (decreased from previous sessions). Engaged and participatory. Arrived on time.

Mood: "Better than usual" (client's words)

Affect: Congruent with stated mood. Full range observed - smiled when discussing success with grounding technique, became tearful briefly when discussing mother. Appropriate to content.

Speech: Normal rate, rhythm, and volume. No pressured speech noted.

Thought Process: Linear, logical, goal-directed. No tangentiality or circumstantiality.

Thought Content: Focused on anxiety management and family relationships. No delusions, obsessions, or paranoid ideation. Denies SI/HI, no evidence of psychosis.

Cognition: Alert, oriented x4. Memory intact for recent events discussed. Insight good - able to identify connection between family dynamics and anxiety symptoms. Judgment adequate.

Standardized Measures:

• GAD-7: 11 (moderate anxiety; was 15 at intake, 13 at session 4)
• PHQ-9: 8 (mild depression; was 14 at intake, 10 at session 4)

Interventions This Session:

• Reviewed and reinforced successful use of grounding techniques (CBT)
• Cognitive restructuring: Examined automatic thoughts about setting boundaries ("I'm a bad daughter if I don't answer"), identified cognitive distortions (all-or-nothing thinking, emotional reasoning), developed balanced alternative thoughts
• Role-play: Practiced assertive communication for upcoming conversation with mother
• Psychoeducation: Discussed concept of "emotional boundaries" vs. "abandonment"

Session duration: 50 minutes

Diagnoses:

• Generalized Anxiety Disorder, moderate (F41.1) - improving
• Major Depressive Disorder, recurrent, mild (F33.0) - improving

Clinical Formulation: Client presents with generalized anxiety and comorbid depression, both showing measurable improvement with combined psychotherapy and pharmacotherapy. Anxiety symptoms appear rooted in early family dynamics characterized by enmeshment and conditional approval. Current conflict with mother is triggering core beliefs about self-worth and fear of abandonment.

Progress: Significant gains evident in symptom reduction (GAD-7 decreased from 15 to 11; PHQ-9 from 14 to 8) and functional improvement (successfully managed panic symptoms at work, improved sleep). Client demonstrating ability to implement coping skills in real-world situations, indicating treatment generalization.

Progress Toward Goals:

• Goal 1 (Manage anxiety at work): PROGRESSING - Successfully used grounding during meeting
• Goal 2 (Sleep 7+ hours): PROGRESSING - Achieving 6-7 hours most nights
• Goal 3 (Family boundaries): PROGRESSING - Beginning to limit contact, working through guilt

Risk Assessment: Low. No current SI/HI, no self-harm urges, adequate social support, engaged in treatment, medication compliant. Protective factors include employment, therapeutic relationship, and cognitive ability to implement coping strategies.

Treatment Plan: Continue weekly individual psychotherapy using integrative CBT approach with emphasis on cognitive restructuring and interpersonal effectiveness skills.

Session Goals for Next Week:

• Process outcome of planned conversation with mother
• Continue cognitive work on guilt and self-worth beliefs
• Introduce behavioral activation to further address depressive symptoms

Homework Assignments:

• Continue daily thought record - focus on boundary-related automatic thoughts
• Practice assertive communication script before conversation with mother
• Continue sleep hygiene protocol
• Schedule one pleasurable activity for the weekend (behavioral activation)

Coordination of Care: Psychiatry follow-up scheduled 2/15 with Dr. Martinez. Will send progress summary prior to appointment. Consider Zoloft dose adjustment if improvement plateaus.

Safety Plan: Reviewed crisis resources. Client has therapist's crisis line number and knows to call 988 or go to ER if SI develops. No changes to safety plan needed at this time.

Next Appointment: 2/5 at 2:00 PM (weekly session)

Patient states "I think it's healing up nicely." Reports no pain at wound site (expected given diabetic neuropathy). Denies fever, chills, or feeling unwell. States blood sugars have been "running high" - reports morning fasting readings between 180-220 mg/dL this week. Admits to "having some birthday cake" at granddaughter's party over the weekend.

Patient reports taking all medications as prescribed: Metformin 1000mg BID, Lisinopril 10mg daily, Atorvastatin 40mg at bedtime. Denies any new medications or changes to regimen.

Spouse present and reports patient has been "pretty good about staying off his feet" but did notice him walking around without his offloading boot yesterday.

Concerns: Patient asks about timeline for healing and whether he'll be able to attend church again soon (requires sitting in pew for 1+ hour).

Vital Signs: BP 142/88 mmHg, HR 78 regular, RR 16, Temp 98.2F oral, SpO2 96% RA

Blood Glucose: 198 mg/dL (fingerstick, 2 hours post-breakfast)

General: Alert, oriented, in no acute distress. Skin warm and dry. Bilateral lower extremity edema 1+ (unchanged).

Wound Assessment - R plantar foot, 1st metatarsal head:

• Dimensions: 1.8 cm (L) x 1.3 cm (W) x 0.2 cm (D) - Previous: 2.2 x 1.5 x 0.3 cm
• Wound bed: 90% granulation tissue (red, beefy), 10% slough (yellow, adherent)
• Exudate: Minimal, serous, no odor
• Periwound: Intact, no maceration, mild callus formation at wound edges
• Signs of infection: None - no erythema, induration, warmth, or purulent drainage

Vascular Assessment: DP pulse 1+ R, 1+ L (palpable, diminished bilaterally). PT pulse 1+ R, 1+ L. Cap refill 4 seconds bilateral toes. ABI not performed this visit (last ABI 0.82 R, 0.78 L on 1/10).

Sensory: Absent protective sensation bilateral feet per 10g monofilament (5/10 sites tested negative bilaterally).

Wound Care Performed:

• Cleansed wound with normal saline, gentle irrigation
• Light debridement of periwound callus using sterile curette
• Applied hydrogel to wound bed
• Covered with non-adherent foam dressing, secured with paper tape
• Reinforced offloading boot application; demonstrated proper use to spouse

Diagnosis: Diabetic foot ulcer, R plantar surface, neuropathic, Wagner Grade 1 (ICD-10: E11.621)

Wound Healing Status: Wound demonstrates progressive healing with 18% reduction in surface area (2.86 cm2 to 2.34 cm2) since last assessment 1 week ago. Wound bed transitioning from mixed granulation/slough to predominantly granulation tissue. No signs of infection. Current healing trajectory suggests wound closure achievable within 3-4 weeks if current progress maintained.

Factors Affecting Healing:

• Positive: Good granulation tissue, no infection, patient engagement in care
• Concerns: Suboptimal glycemic control (fasting 180-220), inconsistent offloading adherence, diminished peripheral circulation

Risk Assessment: Moderate risk for wound deterioration due to neuropathy (cannot feel pressure damage), inconsistent offloading, and glycemic variability. Education and monitoring to continue.

Wound Care Plan: Continue skilled nursing visits 3x/week for wound care, assessment, and patient education. Maintain current dressing protocol (hydrogel + foam). Reassess wound weekly with measurements and photographs.

Patient Education Provided:

• Reinforced importance of offloading boot - must wear at ALL times when weight-bearing, including short trips to bathroom
• Discussed impact of blood sugar on wound healing - reviewed "healing fuel" concept
• Reviewed signs of infection to report immediately (increased redness, warmth, pus, fever, red streaks)
• Encouraged return to diabetic diet; suggested sugar-free alternatives for social events

Care Coordination:

• Will contact PCP Dr. Williams re: glycemic control - request HbA1c if not done recently, consider medication adjustment
• Podiatry follow-up recommended in 2 weeks for callus management
• Dietitian referral placed for diabetic diet review

Goals:

• STG (2 weeks): Wound dimensions reduced by additional 25%; wound bed 100% granulation
• STG (2 weeks): Fasting blood glucose consistently below 180 mg/dL
• LTG (4 weeks): Complete wound closure
• LTG (4 weeks): Patient verbalizes and demonstrates appropriate foot care and diabetic management

Next Visit: Wednesday 1/29. Spouse will be present for additional offloading education.

Chief Complaint: Follow-up for hypertension management

History of Present Illness: Patient returns for 3-month follow-up of hypertension. Reports home BP readings have been "mostly good" - averaging 135/85 per home log. Notes occasional readings in 140s/90s, typically in the evening after stressful workdays. Denies headaches, visual changes, chest pain, or shortness of breath. Reports good medication compliance with Lisinopril 20mg daily, no missed doses. Denies any side effects including cough or dizziness.

Patient has been attempting lifestyle modifications. Reports walking 30 minutes 4-5 days/week (up from 2 days/week). Reduced sodium intake - "trying to avoid the salt shaker and processed foods." Has lost approximately 5 lbs since last visit. Continues to drink 1-2 glasses of wine on weekends.

Review of Systems:

• Constitutional: Denies fever, chills, night sweats. Energy level good.
• Cardiovascular: Denies chest pain, palpitations, edema. No dyspnea on exertion.
• Neurological: Denies headaches, dizziness, weakness, numbness.
• All other systems reviewed and negative unless noted above.

Current Medications: Lisinopril 20mg daily, Atorvastatin 20mg at bedtime, Aspirin 81mg daily, Vitamin D 2000 IU daily

Allergies: Penicillin (rash)

Vital Signs:

• BP: 138/86 mmHg (sitting, R arm); repeat 134/84 mmHg after 5 min rest
• HR: 72 bpm, regular
• RR: 14
• Temp: 98.4F
• Weight: 198 lbs (was 203 lbs 3 months ago)
• Height: 5'10" | BMI: 28.4 kg/m2 (was 29.1)

Physical Examination:

• General: Alert, well-appearing, in no acute distress
• HEENT: Normocephalic, atraumatic. Fundoscopic exam: No AV nicking, hemorrhages, or papilledema.
• Neck: Supple, no JVD, no carotid bruits bilaterally
• Cardiovascular: Regular rate and rhythm. Normal S1, S2. No S3, S4, murmurs, or rubs. PMI non-displaced.
• Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Abdomen: Soft, non-tender, non-distended. No bruits.
• Extremities: No peripheral edema. Pulses 2+ bilateral dorsalis pedis and posterior tibial.

Laboratory Data (from 1 week ago):

• Basic Metabolic Panel: Na 141, K 4.2, Cl 102, CO2 26, BUN 18, Cr 1.0 (eGFR >60), Glucose 98
• Lipid Panel: Total cholesterol 195, LDL 118, HDL 52, Triglycerides 125
• HbA1c: 5.6%

Problem List:

1. Essential Hypertension (I10) - Improving, approaching goal

Blood pressure improved from previous visit (was 148/92, now 134/84 on repeat). Home readings averaging 135/85 indicate better overall control. No evidence of target organ damage on exam. Patient responding to combination of pharmacotherapy and lifestyle modifications. Current regimen of Lisinopril 20mg providing adequate response. Goal BP <130/80 for patient with his cardiovascular risk profile.

2. Hyperlipidemia (E78.5) - Stable, above goal

LDL 118 mg/dL on current Atorvastatin 20mg. Given HTN and ASCVD risk score of 8.2%, LDL goal <100 per ACC/AHA guidelines. May consider statin intensification or addition of adjunct therapy. No statin-associated side effects reported.

3. Overweight (E66.3) - Improving

BMI improved from 29.1 to 28.4 with 5 lb weight loss over 3 months. Patient making sustainable lifestyle changes with regular exercise and dietary modifications. Continued gradual weight loss will further improve BP and lipid control.

Cardiovascular Risk: 10-year ASCVD risk 8.2% (intermediate). Risk factors: Age, HTN, elevated LDL, overweight. Protective factors: Non-smoker, no diabetes, HDL adequate, regular exercise.

1. Hypertension:

• Continue Lisinopril 20mg daily
• Discussed adding low-dose HCTZ 12.5mg if BP remains above goal at next visit
• Continue home BP monitoring; target <130/80
• Reviewed DASH diet principles; provided educational handout
• Encouraged continued sodium restriction and regular exercise

2. Hyperlipidemia:

• Increase Atorvastatin to 40mg at bedtime to achieve LDL goal <100
• Recheck lipid panel in 6 weeks to assess response
• Continue dietary modifications
• Discussed potential side effects of increased statin dose (muscle aches) - call if symptoms develop

3. Overweight:

• Congratulated on 5 lb weight loss - positive reinforcement
• Goal: Continue gradual weight loss, target 185 lbs (BMI 26.5)
• Encouraged increasing exercise to 150 min/week moderate intensity

Health Maintenance:

• Continue Aspirin 81mg daily for primary prevention given intermediate CV risk
• Colonoscopy due - referral placed to GI
• Flu vaccine administered today (lot #FLU2026-A, R deltoid)

Follow-Up: Return in 6 weeks for BP recheck and lipid panel review. Sooner PRN for any concerns. Provided after-hours contact number.

Time Spent: 25 minutes face-to-face, greater than 50% spent in counseling and coordination of care.