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Physical Therapist
10-15 minutes

Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision

The SOAPIER template is an all-encompassing documentation resource designed for physiotherapists to meticulously record patient visits. It encompasses every facet of a clinical encounter, from subjective complaints and objective findings to assessments and treatment plans. This template is perfect for physiotherapists aiming to document detailed patient interactions, monitor progress, and strategize future interventions. The SOAPIER format guarantees the capture of all vital information, making it indispensable for efficient patient management and seamless communication with other healthcare professionals. Optimized for integration with s10.ai, the AI medical scribe, this template enhances documentation efficiency and accuracy.

1,861 uses
4.2/5.0
J
James Chen
Template Structure

Organized sections for comprehensive clinical documentation

Subjective:
- [outline current concerns, visit reasons, discussion points, history of presenting issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [outline past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [list medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [outline social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [list allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective:
- [vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [physical examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [laboratory and imaging results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [diagnosis or differential diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [clinical impression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [treatment plan, including medications, therapies, and follow-up appointments] (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.)
- [referrals to other healthcare providers] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Intervention:
- [describe any interventions performed during the visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Evaluation:
- [patient's response to interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [progress towards treatment goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Review:
- [when the patient is to return] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

Subjective:  
- The patient, a 45-year-old male, reports experiencing lower back pain for the last two weeks, which worsens with prolonged sitting and bending. He has a history of lumbar disc herniation from two years ago.  
- Past medical history includes hypertension and a lumbar discectomy performed in 2021.  
- Current medications include Lisinopril 10 mg daily and Ibuprofen 400 mg as needed for pain.  
- The patient does not smoke, drinks alcohol occasionally, and is employed as an office manager.  
- No known drug allergies.  
Objective:  
- Vital signs: Blood pressure 130/85 mmHg, heart rate 72 bpm.  
- Physical examination shows tenderness in the lumbar area with restricted range of motion in forward flexion.  
- Recent MRI indicates a mild disc bulge at L4-L5 without significant nerve root compression.  
Assessment:  
- Diagnosis: Acute exacerbation of chronic lower back pain due to lumbar disc bulge.  
- Clinical impression: The patient's symptoms align with mechanical back pain.  
Plan:  
- Start a physical therapy program focusing on core strengthening and flexibility exercises.  
- Prescribe a short course of muscle relaxants (Cyclobenzaprine 5 mg at bedtime) for one week.  
- Educate the patient on proper ergonomics and posture at work.  
- Schedule a follow-up appointment in two weeks to evaluate progress.  
Intervention:  
- Conducted manual therapy techniques including soft tissue mobilization and lumbar traction.  
Evaluation:  
- The patient reported immediate relief in muscle tension following the intervention.  
- Progress towards treatment goals will be assessed in the next session.  
Review:  
- The patient is to return for a follow-up visit in two weeks.
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, making it an invaluable tool for clinicians. The template is structured to capture detailed subjective and objective data, including patient history, vital signs, and examination findings, while also facilitating thorough assessment and planning. It supports the documentation of interventions and evaluations, promoting continuity of care and improved patient outcomes. Clinicians are encouraged to adopt this template to enhance their practice, improve patient communication, and ensure compliance with medical documentation standards.
Frequently Asked Questions

Common questions about this template and its usage

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Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision