Physio SOAP Outpatient
Created by
Kim Nguyen
Specialty
Physiotherapist
Last edited
10/20/2026
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0 times
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About this template
This template supports outpatient physiotherapy documentation across the patient’s current condition, objective findings, treatment, assessment, and plan. It captures relevant adherence, medication use, symptoms, clinical observations, interventions, goals, progress, and follow-up arrangements.
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Current Condition/Complaint
- R shoulder pain decreased from 6/10 to 3/10 on VAS since last session on 07/05/2024; sleeping through the night on L side without waking.
- Mild R upper trapezius ache after prolonged desk work.
- 100% adherent to HEP; avoided overhead lifting at the gym as advised.
- Ibuprofen (Nurofen®) 400 mg PO PRN; used once in the past week post-work.
- R shoulder US (10/05/2024): Mild supraspinatus tendinosis with subacromial bursal thickening; no tear identified.
Objective
- Observation: Mildly protracted R scapula at rest.
- R shoulder AROM: Flexion 160° (painful arc 90°–120°), abduction 150° (3/10 pain at end-range), ER at 0° abduction 60° (NAD), HBB to T10 (tightness only).
- Strength (MMT): R supraspinatus (empty can) 4/5 with 2/10 pain, R ER at 0° 4+/5 (NAD), R IR 5/5 (NAD).
- Special tests: Hawkins-Kennedy (+), Neer's (-).
- Palpation: Tender over R greater tuberosity and upper trapezius.
Treatment
- Reviewed US findings; reassured pt regarding absence of rotator cuff tear and discussed load management during desk duties.
- STM to R upper trapezius and pectoralis minor; Grade III AP glenohumeral joint mobilisations (3 x 60 s).
- Supervised clinic exercises: Scapular setting, resistance band ER at 0° abduction, and wall slides with foam roller.
- Updated HEP:
- Yellow TheraBand® R shoulder ER at 0°: 3 sets of 12 reps, once daily.
- Serratus anterior wall slides: 3 sets of 10 reps, once daily.
- Pectoralis doorway stretch: 3 sets of 30 s holds, BID.
Assessment
- R subacromial pain syndrome / supraspinatus tendinopathy.
- Steady improvement in AROM and reduction in night pain since initial consult two weeks ago.
- Progressing well toward goal of returning to overhead weights at the gym; currently tolerating waist-level exercises pain-free.
- Prolonged sitting and suboptimal ergonomic setup at work contributing to persistent scapular protraction.
Plan
- Continue current load management and progressed HEP to build rotator cuff endurance.
- Review in 1 week (21/05/2024 at 09:30 AWST).
- Reassess AROM and strength; progress to ER at 45° abduction and introduce closed-chain scapular stability exercises.
- Pt booked for ergonomic workstation assessment via occupational health at work this Friday.
- Send brief progress update letter to referring GP, Dr Sarah Jenkins.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.