Physio Comprehensive SOAP

**Physiotherapy SOAP Note** **Date:** [date of consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Use format DD/MM/YYYY.) **Patient Details:** [patient name, age, gender, date of birth, contact details, dominant hand] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as brief paragraph.) **Referral Information:** [referral source, referral date, reason for referral, funding source such as medical aid or private or RAF, medical aid name and plan, claim number if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **SUBJECTIVE** **Chief Complaint:** [patient's primary complaint in their own words including body region affected] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences with verbatim text for patient's own words.) **History of Presenting Complaint:** [description of current problem, onset, progression since onset, current symptom status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs.) **Mechanism of Injury:** [mechanism of injury including date, specific incident, position, forces involved, immediate symptoms. For MVA include driver or passenger, seatbelt, airbag. For workplace injury include location, activity, reporting to employer. For gradual onset describe contributing activities.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs.) **Pain Assessment (Patient-Reported):** - Location: [specific anatomical area] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Intensity: [pain at rest /10, pain with activity /10] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Type: [quality such as sharp, dull, aching, burning, stabbing, throbbing, shooting] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Neurological symptoms: [tingling, burning, pins and needles, numbness, heaviness, weakness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Referred pain: [distribution pattern, dermatomal or myotomal pattern] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Behaviour: [constant versus intermittent, frequency, duration of episodes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - 24-hour pattern: [morning pain, stiffness and duration, daytime pain, evening pain, night pain, effect on sleep, pain at rest versus with movement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Aggravating Factors:** [activities, positions, or movements that increase symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Alleviating Factors:** [activities, positions, or strategies that decrease symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Associated Symptoms:** [swelling, weakness, instability, clicking, locking, giving way, catching, grinding, stiffness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Previous Treatment for Current Condition:** [previous investigations and results, previous treatments and effectiveness, current treatments and self-management] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Past Medical History:** [medical conditions, previous surgeries, previous musculoskeletal injuries, relevant comorbidities such as diabetes, hypertension, HIV, TB, cardiovascular, respiratory, osteoporosis, arthritis, cancer, mental health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Medications:** [current medications with dose and frequency, OTC medications, supplements, traditional remedies, recent changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Allergies:** [known allergies and nature of reaction, adverse reactions to treatments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Social History:** **Living Situation:** [dwelling type, single or double storey, stairs to enter house and internal stairs, handrails, bedroom location, bathroom setup with shower or bath, step into bath, shower chair or bath board, grab rails, flooring type, who patient lives with, support available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points with each topic on a new line.) **Mobility Status:** - Baseline (prior to current condition): [independent ambulation, use of aids, distance, stairs, driving] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Current: [level of independence, aids in use, assistance required, distance, stairs, driving, changes from baseline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Occupation:** [job title, employer if relevant for RAF, employment status, physical demands, specific job tasks, hours per week, current work status, duration off work or on modified duties] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Lifestyle:** - Smoking: [status, cigarettes per day, pack year history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Alcohol: [consumption status, amount and frequency] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Recreational activities: [sports, hobbies, exercise habits, impact of current condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Functional Limitations (Patient-Reported):** [impact on daily activities, self-care, household tasks, work duties, recreational activities, use of aids] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs.) **Red Flag Screening:** [list any red flags screened and their status as negative or positive. Include unexplained weight loss, fever or night sweats, unrelenting night pain, constant pain unaffected by position, history of cancer, recent trauma, progressive neurological symptoms, bilateral neurological symptoms, cauda equina symptoms such as saddle anaesthesia or bladder or bowel dysfunction or bilateral leg weakness, thoracic pain with risk factors, age over fifty or under twenty with new onset back pain, immunosuppression including HIV, IV drug use, recent infection or TB history, symptoms worsening despite treatment, systemically unwell] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list with status noted.) [action taken for any positive red flags] (Only include if positive findings identified in transcript, contextual notes or clinical note, else omit entirely.) **Yellow Flag Screening (Psychosocial Risk Factors):** [list any yellow flags identified such as fear avoidance behaviour, belief that pain is harmful, expectation of passive treatment, low mood or depression, catastrophising, social withdrawal, financial stressors, compensation or medico-legal involvement, job dissatisfaction, extended time off work previously, lack of social support] (Only include if relevant factors identified in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Patient Goals:** [patient's main goals for physiotherapy, expectations for recovery timeframe, goals for return to work, sport, and daily activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as numbered list.) **OBJECTIVE** **Observation:** [general appearance, willingness to move, pain behaviours, guarding, facial expressions, use of aids, body habitus] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Posture:** [standing posture including head position, spinal curves, pelvic position, shoulder and scapular symmetry, lower limb alignment, foot posture; sitting posture; deviations and asymmetries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Gait:** [gait pattern including cadence, stride length, symmetry, stance and swing phases, heel strike, toe off, arm swing, trunk movement; deviations such as antalgic, Trendelenburg, foot drop, circumduction; use of aids and assistance level; distance and tolerance; stair climbing ability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Inspection:** [skin colour, swelling, bruising, scars, muscle bulk, wasting, deformity, asymmetry compared to contralateral side] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Palpation:** [specific structures with tenderness graded as mild, moderate, or severe; muscle tone, tension, spasm, trigger points; temperature changes; swelling, effusion, crepitus; bony alignment; joint line tenderness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Range of Motion:** **Active ROM:** [joint, movement, degrees left and right, quality of movement, pain response, arc of pain, compensations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list in format: Joint - Movement: Left / Right (notes).) **Passive ROM:** [joint, movement, degrees left and right, end feel, pain response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list in format: Joint - Movement: Left (end feel) / Right (end feel) (notes).) **Accessory Joint Movements:** [joint, direction of glide, mobility grading, pain response, comparable sign reproduction] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Muscle Length:** [muscle tested, side, result as normal or shortened or lengthened, pain response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Muscle Strength (Oxford Scale 0-5):** [muscle or movement tested, left grade /5, right grade /5, pain response, pattern of weakness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list in format: Movement/Muscle: Left /5, Right /5 (notes).) **Neurological Examination:** - Sensation: [modality, dermatomal distribution, findings comparing left to right] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Reflexes: [reflex with nerve root, grading as absent, diminished, normal, brisk, or hyperactive, comparing left to right] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Myotomes: [key muscle, nerve root level, comparing left to right] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Upper motor neuron signs: [Babinski, Hoffmann, clonus with results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Neurodynamics: [test name, side, result, symptoms reproduced, structural differentiation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) - Other neurological tests: [any additional neurological tests performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Special Tests:** [test name, structure or pathology tested, side, result as positive or negative, interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Functional Tests:** [test name, result, comparison to norms or contralateral side, limb symmetry index if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Cardiovascular and Respiratory Assessment:** [vital signs, auscultation, chest expansion, cough assessment, exercise tolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Outcome Measures:** [measure name, score, interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Pain Response During Examination:** [movements, tests, or palpation that reproduced symptoms; severity of response; concordant versus discordant signs; centralisation or peripheralisation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **ASSESSMENT** **Clinical Diagnosis:** [primary diagnosis including anatomical structure, pathology, laterality, stage; secondary diagnoses or contributing conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Differential Diagnoses:** [differential diagnoses with reasoning] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Clinical Reasoning Summary:** [summary of key subjective and objective findings supporting diagnosis; correlation between findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs.) **Contributing Factors:** [biomechanical, postural, muscle imbalance, movement dysfunction, neural, load management, training errors, ergonomic, psychosocial, lifestyle, systemic factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Precautions and Contraindications:** [precautions and contraindications for treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Prognosis:** [expected prognosis, positive and negative prognostic factors, expected timeframe for recovery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Problem List:** [prioritised list of problems identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as numbered list.) **PLAN** **Treatment Goals:** - Short-term: [specific, measurable goals with timeframes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as numbered list.) - Long-term: [specific, measurable goals with timeframes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as numbered list.) - Functional goals: [patient-centred goals for return to work, sport, daily activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as numbered list.) **Treatment This Session:** **Manual Therapy:** [joint mobilisation with joint, grade, direction, sets, duration, response; manipulation if performed; mobilisation with movement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Soft Tissue Techniques:** [massage techniques, trigger point therapy, myofascial release, instrument assisted soft tissue mobilisation with details and response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Dry Needling:** [muscles needled, needle size, depth, technique, local twitch response, duration, electrical stimulation if used, patient response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Exercise Therapy:** [exercise name, purpose, sets, reps, hold time, resistance, technique cues, progressions or regressions, patient performance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Neuromuscular Re-education:** [motor control exercises, proprioceptive training, balance training with details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Electrotherapy and Physical Agents:** [modality, parameters, application area, treatment time, response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Taping and Bracing:** [type, technique, purpose, area, wearing instructions, response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Gait and Functional Training:** [focus of training, aids used, distance, assistance level, cues provided, progressions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Other Interventions:** [any other interventions such as acupuncture, cupping, hydrotherapy, vestibular rehabilitation, respiratory physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Response to Treatment:** [immediate response including changes in pain, ROM, strength, function, movement quality; objective changes post-treatment; patient feedback; adverse responses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Patient Education:** [education on diagnosis, contributing factors, pain neuroscience, activity modification, posture and ergonomics, load management, return to work and sport advice, warning signs, resources provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Home Exercise Program:** [exercises with name, purpose, sets, reps, hold time, frequency, resistance, technique points, progressions; method of delivery; patient understanding confirmed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Self-Management Strategies:** [ice or heat application, activity pacing, relative rest, sleep positioning, ergonomic modifications, flare-up management] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Referrals and Recommendations:** [referrals to other professionals with reason; recommendations for investigations; equipment recommendations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet point list.) **Work Capacity:** [current work capacity, fit for full or modified duties or unfit, specific restrictions, sick note issued, expected return to full duties, workplace assessment recommended] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.) **Follow-Up Plan:** [next appointment, recommended review timeframe, planned focus for next session, criteria for progression, criteria for discharge, red flags to monitor] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)