Physical Therapist Assistant how-to
How to Write a SOAP Note
Accurate documentation supports patient care, communication and payment.
Accurate documentation supports patient care, communication and payment. In short: subjective; objective; assessment, then complete the remaining steps below.
Step by step
Subjective: record what the patient reports, such as pain level and how they’re doing at home.
Objective: record measurable data and the treatments performed, with sets, reps and minutes.
Assessment: describe the patient’s response and progress toward goals.
Plan: note the next steps and anything to discuss with the physical therapist.
Sign and complete the note on time, following your facility’s rules.
Safety reminders for physical therapist assistants
- Use gait belts and proper guarding for every mobility task
- Check vital signs when patients have cardiac or blood pressure concerns
- Use good body mechanics and ask for help with heavy patients
- Clean equipment between patients
Key terms
Plan of care · ROM · AROM and PROM · Gait training · Assistive device · Weight-bearing status: see the full physical therapist assistant glossary.