Key takeaways
In this guide, we'll cover the following in detail:
Essential Documentation for Physical Therapists – Learn the must-have records for tracking patient progress, including SOAP notes, initial evaluations, and discharge summaries.
How to Write SOAP Notes (With Examples) – Understand the SOAP format (Subjective, Objective, Assessment, Plan) with real-world physical therapy documentation examples.
Download a Free Google Docs Template – Save time with a ready-to-use physical therapy documentation template, designed for efficiency and ease.
Google Docs vs. EZbook – Discover why EZbook is a smarter alternative to Word and Excel, helping therapists automate documentation.
Boost Efficiency & Accuracy – Learn best practices to reduce errors, improve compliance, and spend more time with patients instead of paperwork.
📥 Get Your Free Physical Therapy Documentation Template Now! – Click here to download and start using it today for streamlined patient record-keeping.
Table of Contents
What are the essential types of documentation for physical therapists?
What Are the Most Common Physical Therapy Documentation Formats?
Physical therapy sample documentation: How to Write SOAP Notes (With Examples)?
Get the best physical therapy documentation cheat sheet (Google Doc template)
Streamline Your Physical Therapy Documents – Download Your Free Template Today!
Introduction
As a physical therapist, what is the most challenging part of your job? We bet it is managing the quality of patient care while handling routine tasks.
Staying on top of physical therapy documentation isn’t just about ticking boxes. It’s the key to delivering top-notch treatment. Good documentation helps you track progress, stay consistent, and check off all those legal and insurance requirements.
Google Docs or Microsoft Word are basic tools to manage all your documentation. They are budget-friendly, flexible, and easy to work with, whether you are managing a short-term injury or tracking a long rehab journey.
In this guide, we are exploring the best practices for physical therapy documentation and physical therapy notes examples. Plus, get your hands on a free downloadable PDF template and some alternative tools to make your workflow smoother.
If you’re looking for an easier way to manage your documentation, we have a free coaching app that lets you track your documentation with ease - EZbook. More on this later.
Let’s get into it!
What are the essential types of documentation for physical therapists?
As a physical therapist, you can use point-of-service documentation to record various aspects of a patient's treatment journey. Let’s have a look at some of the forms:
Initial evaluations: A comprehensive assessment of the patient's condition, medical history, and treatment goals.
Daily progress notes in SOAP format: A structured record of each therapy session, including patient-reported symptoms, measurable data, therapist assessments, and future treatment plans.
Re-evaluations: Periodic assessments to measure improvements, adjust treatment plans, and determine the next steps in therapy.
Discharge summaries: A final report summarizing the patient's progress, outcomes, and any recommendations for continued care after therapy ends.
What Are the Most Common Physical Therapy Documentation Formats?
Understanding documentation also means you must learn when documentation should be recorded and what is the use of each one.
The SOAP framework ensures physical therapists can easily track patient progress and adjust treatment plans accordingly. This is one of the best documentation practices. So, here’s a detailed breakdown of the format.
S – Subjective (Patient's perspective)
You can get information from the patient's POV from the subjective section in the SOAP format. It records their reported symptoms, pain levels, functional difficulties, and concerns related to their condition.
The subjective section is often obtained through patient interviews and helps therapists understand how the condition is impacting daily life.
Key elements:
Patient’s chief complaint (reason for seeking treatment).
Description of pain, discomfort, or movement restrictions.
Details about onset, frequency, and aggravating or relieving factors.
Feedback on previous treatments or home exercises.
O – Objective (Measurable data)
The objective section includes quantifiable and observable data collected by the therapist. This information is gathered through physical assessments, functional tests, and treatment interventions provided during the session. The objective data ensures accurate diagnosis and treatment planning.
Key elements:
Range of motion measurements
Muscle strength testing results.
Gait analysis, balance assessment, and posture evaluation.
Vital signs, if relevant (heart rate, blood pressure, oxygen saturation, etc.).
Description of treatments administered
A – Assessment (Clinical judgment & diagnosis)
The assessment section includes the therapist's professional evaluation of the patient’s current condition, progress, and response to treatment. It helps to determine whether the treatment plan is effective or requires modifications.
Key elements:
Progress evaluation compared to previous sessions.
Challenges or setbacks encountered by the patient.
Effectiveness of current interventions.
Justification for continued treatment or need for modifications.
P – Plan (Future treatment strategy)
The plan section outlines the next steps for treatment, including future therapy sessions, home exercise recommendations, and expected goals. A clear plan helps ensure continuity of care and keeps both the therapist and patient aligned on treatment objectives.
Key elements:
Number of future sessions planned.
Treatment modifications are based on progress.
Home exercise programs (specific exercises, frequency, and duration).
Referral to other specialists (if needed).
Physical therapy sample documentation: How to Write SOAP Notes (With Examples)?
SOAP notes are a standardized method for documenting patient progress in physical therapy. Below are detailed physical therapy documentation examples illustrating how SOAP notes are used at different stages of rehabilitation.
Example 1: Initial Evaluation SOAP Note
Patient Name: John Doe Date: 02/12/2025 Diagnosis: Post-op ACL Reconstruction
S (Subjective):
The patient reports knee pain (6/10) and stiffness following ACL reconstruction surgery.
Difficulty walking, especially on uneven surfaces, and climbing stairs.
Reports mild swelling and discomfort after prolonged sitting.
O (Objective):
Range of Motion (ROM): 0-90° knee flexion
Strength Testing:
Quadriceps: 3/5
Hamstrings: 4/5
Gait Analysis: Antalgic gait pattern with noticeable favoring of the surgical leg.
Swelling: Mild effusion present around the knee joint.
A (Assessment):
Post-surgical knee weakness and stiffness are limiting mobility and functional activities.
The patient demonstrates reduced quadriceps activation, contributing to gait compensations.
P (Plan):
Initiate gentle range of motion exercises to improve knee flexibility.
Begin quadriceps and hamstring strengthening with low resistance.
Educate the patient on swelling management (ice, elevation).
Gait training to promote even weight distribution.
Re-evaluate in two weeks to assess progress.
Example 2: Daily Progress SOAP Note
Date: 02/15/2025 Treatment Session: Post-op ACL Rehabilitation
S (Subjective):
Patient reports decreased knee pain (4/10) but still experiences discomfort when descending stairs.
Notes reduced swelling compared to the previous session.
O (Objective):
ROM: Improved to 0-110° flexion
Strength Testing:
Quadriceps: 4/5
Exercises Performed:
Quad sets, straight leg raises
Mini squats with support
Step-ups on a 4-inch platform
Static balance exercises
A (Assessment):
Patient is progressing well in strength and range of motion.
Improved knee stability and control were observed during exercises.
P (Plan):
Increase resistance in strengthening exercises.
Introduce single-leg balance drills to enhance proprioception.
Continue pain management techniques as needed.
Monitor for swelling after activity and adjust the intensity accordingly.
Example 3: Discharge Summary (SOAP Format)
Date: 03/20/2025 Diagnosis: Post-op ACL Rehabilitation Completed
S (Subjective):
Patient reports feeling strong and confident with daily activities.
No significant pain, occasional mild stiffness after prolonged sitting.
O (Objective):
ROM: Full knee flexion achieved (0-130°)
Strength Testing:
Quadriceps: 5/5
Hamstrings: 5/5
Functional Tests:
Normal gait pattern restored.
Successfully performs single-leg squats and dynamic balance drills.
Able to walk, run short distances, and climb stairs without difficulty.
A (Assessment):
Patient has met physical therapy goals, demonstrating restored strength, mobility, and functional independence.
P (Plan):
Discharge from physical therapy with a comprehensive home exercise program.
Continue strengthening and proprioception exercises 3-4 times per week.
Gradual return to sports with proper warm-up and strengthening.
Follow-up with the orthopedic surgeon in one month
Get the best physical therapy documentation cheat sheet (Google Doc template)
Using a structured template in Word or Excel offers several benefits for physical therapists:
Time efficiency: Eliminates the need to start documentation from scratch for every patient, allowing for quick and consistent record-keeping.
Standardized format: Ensures uniform documentation across all patient records, making it easy to review and update treatment plans.
Customizable for your needs: Modify templates to include specific fields, such as range of motion tracking, exercise logs, or session notes.
Easy access and sharing: Store files on cloud platforms (Google Drive, OneDrive) or share them with team members, insurance providers, or referring physicians.
Works offline: No need for internet access – simply open the document and input patient details anytime.
Download Your Free Physical Therapy Google Doc Template
To help you simplify your documentation process, we’ve designed a ready-to-use Physical Therapy Documentation Template available in both Word and Excel formats.
What’s Included?
Patient intake and evaluation forms – Capture initial patient details and history.
SOAP Note template – Document session progress in a structured format.
Daily progress and treatment logs – Track exercises, treatments, and improvements.
Discharge summary template – Summarize final patient progress and future recommendations.
A simple and free alternative to using Microsoft Word / Google Docs for your physical therapy sessions
While Microsoft Word and Google Docs are common tools for physical therapy documentation, they require manual data entry, organization, and formatting—which can be time-consuming.
If you are looking for a more efficient, automated, and easy-to-use alternative, EZbook offers a customizable solution designed to streamline patient documentation, session tracking, and progress monitoring.
Why Choose EZbook Over Word/Excel for Physical Therapy Documentation?
Unlike traditional word processors and spreadsheets, EZbook is built for therapists, offering customizable templates, an intuitive interface, and automation features that make documentation effortless. Here’s why it stands out:
Customizable documentation – Create and personalize physical therapy templates tailored to your practice, from SOAP notes to exercise logs.
Easy-to-use interface – No need for complex formatting like in Word or Excel; just create a template, fill in details, and save instantly.
Automation & smart features – Automatically track patient progress, set reminders for follow-ups, and generate reports without manual calculations.
Why EZbook is the Best Free Alternative for Physical Therapy Documentation
Features | EZbook | Word/Excel sheet |
Customizing data for each client | Automated | Manual effort needed |
Session scheduling and tracking | Automated | Manual effort needed |
Multi-device compatibility | Available | Available |
Simplify Your Physical Therapy Documentation – Get Your Free Template Now!
Keeping track of patient progress shouldn’t be a hassle. With the right documentation tools, you can save time, ensure accuracy, and improve patient outcomes. Whether you prefer a Word/Excel template for manual record-keeping or an automated solution like EZbook, having a structured system in place is essential for effective therapy management.
Get your free physical therapy documentation template now! Download and start using it today.
Looking for a more advanced, automated solution? EZbook lets you save all these templates and access them on the go—on your mobile app or desktop—in a fast, convenient way, so you can focus more on patient care!
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