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Physical Therapist
10-15 minutes

SOAPIE - Physical Therapy

The SOAPIE Physiotherapy template by s10.ai is an all-encompassing documentation tool crafted for physiotherapists to meticulously record patient interactions. Utilizing the SOAPIE format, it captures essential elements such as Subjective, Objective, Assessment, Plan, Intervention, and Evaluation, making it perfect for documenting patient history, physical exam results, treatment strategies, and progress tracking. This structured methodology guarantees comprehensive and uniform documentation, facilitating effective patient management and seamless communication with other healthcare professionals. Optimized for s10.ai, this template significantly boosts the efficiency and precision of clinical note-taking in physiotherapy environments, encouraging clinicians to explore and implement this advanced solution.

1,960 uses
4.2/5.0
J
Jonathan Mitchell
Template Structure

Organized sections for comprehensive clinical documentation

Subjective:
- [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [laboratory and diagnostic test results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective:
- [document physical examination findings, observations, and measurements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [provide clinical assessment, diagnosis, and clinical impressions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [provide a problems list] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [outline treatment plan, including any prescribed exercises, therapies, or interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [patient education and counseling] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention follow-up plans and any referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Intervention:
- [describe the specific interventions performed during the session, including manual therapy, exercises, modalities, and patient education] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any exercises or techniques demonstrated to the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [note any adjustments made to the treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe patient education or advice given] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Evaluation:
- [document the patient's response to the interventions, including any changes in symptoms, function, or range of motion] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [note any progress towards treatment goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe any new issues or concerns raised by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any adjustments to the treatment plan based on the patient's response] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Subjective:  
- The patient, a 45-year-old office employee, describes a sedentary lifestyle with minimal physical activity.  
- The patient experiences lower back pain persisting for the last three weeks, worsened by extended sitting and relieved by standing or walking.  
- Past medical history includes a lumbar disc herniation diagnosed two years ago, with no surgical interventions.  
- Recent MRI results indicate mild degenerative changes in the lumbar spine.  
- The patient is currently using ibuprofen as needed for pain management.  
- No known allergies.  
Objective:  
- Physical examination shows tenderness in the lumbar area, decreased range of motion in forward flexion, and mild muscle spasm in the lower back.  
Assessment:  
- Clinical evaluation suggests mechanical lower back pain likely due to muscle strain and poor posture.  
- Problems list: 1. Lower back pain 2. Reduced lumbar mobility 3. Muscle spasm  
Plan:  
- The treatment plan includes a program of core strengthening exercises, postural training, and manual therapy.  
- Patient education on ergonomics and the significance of regular physical activity was provided.  
- Follow-up appointment set for two weeks, with a referral to a pain management specialist if symptoms continue.  
Intervention:  
- Manual therapy techniques, including soft tissue mobilization, were administered.  
- Demonstrated core stabilization exercises to the patient.  
- Modified treatment plan to incorporate additional stretching exercises.  
- Advised the patient on maintaining proper posture during daily activities.  
Evaluation:  
- The patient reported a slight decrease in pain and improved mobility post-intervention.  
- Progress observed towards achieving increased range of motion.  
- No new issues or concerns were reported by the patient.  
- Treatment plan adjustments include increasing the intensity of exercises as tolerated.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of patient encounters. By incorporating high-search healthcare and clinical keywords, this template enhances the visibility and accessibility of clinical notes. It covers all essential components, including subjective and objective data, assessment, and plan, allowing clinicians to capture detailed patient information, from medical history to physical examination findings. The template also facilitates the documentation of interventions and evaluations, ensuring a thorough record of patient care. By adopting this template, clinicians can improve workflow efficiency, enhance patient care quality, and ensure compliance with clinical documentation standards. Explore this template to optimize your clinical documentation process today.
Frequently Asked Questions

Common questions about this template and its usage

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SOAPIE - Physical Therapy