What SOAP gives you, and what it does not
SOAP stands for Subjective, Objective, Assessment and Plan. It is a shape, not a script. The shape helps in three ways: you never forget a part, a colleague finds what they need quickly, and a note written months later still makes sense.
What it does not do is decide how much to write. That is your template's job. If the template shows twelve headings, you will feel obliged to fill twelve.
Find and open the template
Go to Manage → Note templates. New practices start with a physiotherapy set that includes an initial assessment, a SOAP follow-up, a post-operative knee note, a vestibular note and a sports injury note. You can edit any of them or build your own.
Open the SOAP follow-up and look at it as if you were seeing a patient in six minutes' time. Ask of each field: did I use this last week? If the answer is no, take it out.
One point removes the fear of tinkering. Changing a template never rewrites old notes. Every note written earlier stays exactly as it was signed. So you can trim today without touching a single record.
Trim it to your caseload
The right short template depends on who you treat.
- Mostly musculoskeletal outpatients: keep a line for the patient's report, one repeated measure, the treatment and its dose, and the plan.
- Post-operative patients: add a field for the stage of recovery and the surgeon's instructions, since those drive the plan.
- Home visit work: a short space for the setting and anything that affected the session.
- Sports and performance: the return-to-play step you are working on.
If you treat several types, keep a short SOAP follow-up and a separate template for each type rather than one long form with sections for everyone. A body chart can sit in the note when the location matters, and owners can design the charts on offer.
An example follow-up skeleton
Treat this as a starting point to paste into your own template, then cut it further:
S, Subjective
- Change since last visit: better, same or worse, in the patient's words
- Main difficulty this week, and one thing they did or could not do
- Anything new to report
O, Objective
- One repeated measure or key movement, with the result
- Treatment given, with the dose
A, Assessment
- Progress toward the goal, in one or two lines
- Anything that changes the plan
P, Plan
- Next visit and what it will cover
- Advice given
- Review date
If you use outcome measures, record them against the case. Measures belong to a case, so a knee score and a back score never mix, and repeating a measure charts the trend for you. Outcome measures and progress tracking shows how.
Mistakes that make SOAP notes long and vague
- The essay in the S. Write what changed, not the patient's whole story again.
- Copy-forward. Pasting last week's note makes the record look full and tells the next reader nothing.
- An A that repeats the S. Assessment is your judgement, not a second summary.
- No dose in the O. "Manual therapy and exercises" is hard to repeat or review. Record what, how much and where.
- A P that says "continue". Say what is next and when you will review.
- Finishing the notes on Friday. By then you are reconstructing, not recording.
Keeping the habit: saves, drafts and signing
Clinidiary saves a note as you type. If the connection drops, it keeps a copy on the device and saves it when you are back online, so a patchy signal does not lose your work.
A note is a draft until you sign it. Signing locks it, and any later correction is a dated amendment while the original stands. That is useful when a funder or insurer asks for your record.
Your Dashboard has an Uncompleted notes card showing your own unsigned notes. Make clearing it the last job of the day and the Friday pile never forms. If you work alone, faster treatment notes for solo physios has more routines for keeping up.
A faster start from free templates
If you would rather start from something written for a condition, open Settings → Resources library and use Add to my practice. The note templates there include low back pain, neck pain, shoulder pain, knee osteoarthritis, ankle sprain, total knee replacement, ACL reconstruction, falls risk and stroke rehabilitation, each naming its guideline. They are prompts, not protocols, so edit them to match how you practise. See free evidence-based note templates for the list, and treatment notes, templates and body charts for how the notes fit into the rest of the record.
Frequently asked questions
What is a SOAP note in physiotherapy?
A SOAP note records a visit in four parts: Subjective (what the patient reports), Objective (what you measured and did), Assessment (your judgement) and Plan (what happens next).
How long should a physio follow-up note be?
As short as it can be while still letting a colleague pick up the case. A few lines in each part is usually plenty, and the template should only ask for what you actually use.
If I change my template, will it change my old notes?
No. Changing a template never rewrites old notes. Earlier notes stay as they were written and signed.
Can I correct a note after I have signed it?
Yes, by adding a dated amendment. The signed note is locked and the original stands, with the correction recorded beside it.