SOAP Note Example (Complete, Annotated)
Below is a full SOAP note as produced by the SOAPNote generator for a physical therapy follow-up, followed by a breakdown of why each part works. The same structure adapts to occupational therapy, massage, counseling and speech-language pathology — only the Objective fields change.
Riverside PT
Jane Doe, PT, DPT — (555) 123-4567
Patient: J.M. | Date: 2026-08-23 | Duration: 45 min | Follow-up | CPT: 97110
Subjective
- Chief complaint: Patient reports low back pain, worse after prolonged sitting.
- Reported pain: 4/10
- Since last session: improved
- Symptoms: Morning stiffness now under 20 minutes; no radiating pain this week.
- Patient states: “I walked the dog twice this week without stopping.”
- Patient goals: Return to running 3×/week.
Objective
- ROM (deg): 120 (lumbar flexion, was 105 on 08/16)
- Strength: 4/5 (abdominals, trunk flexion)
- Balance: single-leg stance 30 s bilaterally
Interventions: therapeutic exercise, manual therapy
Soft tissue mobilization lumbar paraspinals 10 min; core stabilization progression, 3×10.
Assessment
- Progress toward goals: improving
- Response to treatment: tolerated well
- Lumbar ROM improving as expected; +15° flexion in one week with decreased morning stiffness supports continued skilled PT with progression to loading.
Plan
- Frequency: 2×/week for 4 weeks
- Home program: Daily cat-camel and bird-dog, 2 sets of 10; walk 20 min/day.
- Next session: 2026-08-26
- Progress to standing strength work and running prep as tolerated; will update referring physician at week 4.
Electronically signed by Jane Doe, PT, DPT
Why this note works
The Subjective section has a voice
One verbatim does three jobs: it documents function (walking), engagement (did it twice), and outcome (without stopping). The pain rating and the “since last session” line give the Objective section something to confirm.
The Objective section shows change
“120°, was 105 on 08/16” is the single most valuable habit in progress documentation: the same measure, comparable across visits, with the delta visible. Interventions carry dosage — 10 minutes, 3×10 — which is what justifies the billed unit.
The Assessment connects findings to the plan
It doesn't restate the Objective section; it interprets it. “+15° in one week… supports continued skilled PT with progression to loading” is the sentence a reviewer needs to authorize the next four weeks.
The Plan is checkable
Frequency, home program, next date, and a named progression. At the next visit, every item can be verified: did the HEP happen, did progression occur?
Adapt it to your discipline
The skeleton never changes; the measurement fields do. A counselor replaces ROM with affect, mood and risk assessment; an SLP replaces it with articulation accuracy and cueing levels; a massage therapist with tissue response and tension ratings. The generator ships these variants built in — pick your discipline and the fields, interventions and phrasing follow.
Use this example as your starting point: open the free template, fill your session, and export the PDF. The note above was produced by the tool without any manual formatting.
Frequently asked questions
Can I copy this example?
Yes — it's a realistic, fictional example. Better: open the generator and produce your own with the same structure.
How long should a SOAP note be?
Long enough to justify the care: typically 150–300 words for a routine follow-up. Structure matters more than length.