A rehabilitation SOAP note example and template for any discipline, with each session activity tied to a shared team goal.
✓Works for PT, OT, SLT, psychology
✓Activities linked to shared goals
✓Handover table for nursing and family
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What's inside
S — Subjective
O — Objective
A — Assessment
P — Plan
Handover to the Team
Therapist Sign-off
Preview · 6 sections
Rehabilitation SOAP Note
Patient
Session date
Discipline
Therapist
Session type (individual, group, co-treatment)
Session length
Location (ward, gym, home, community)
Carer present
S — Subjective
Patient reportPain, tiredness, sleep, mood and anything since the last session, in the patient's words where possible.
Carer or staff reportName who reported it: family member, attendant, or ward staff.
O — Objective
Shared Goal
Activity
Data (assistance, repetitions, distance, time, cues)
Notes
Goal 1
Goal 2
Goal 3
ObservationsSetting, equipment used, tolerance, rest breaks, and how the patient responded.
A — Assessment
Interpretation of sessionYour professional interpretation of today compared with recent sessions and the shared goal.
P — Plan
Plan for next session
Practice between sessionsWhat was set, who will supervise it, and how it was taught.
Handover to the Team
For
What They Need to Know
Action
Nursing
Other therapists
Family / carer
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
S — Subjective
Record what the patient and any carer or staff reported, naming who said what.
More guidance
Record what the patient told you about pain, tiredness, sleep, mood and anything that happened since the last session, quoting them where the exact words add meaning. Add a separate line for what a carer, attendant or ward staff reported, and say who it came from. If the patient could not give a report, note how you tried and what you observed instead.
2
O — Objective
One row per activity, linked to a shared goal, with data the next session can compare.
More guidance
One row per activity. Link it to the shared goal number, describe the activity, and give data the next session can compare against: level of assistance, repetitions, distance, time, number of cues or prompts, rest breaks. Use the same units as the goal plan. Below the table, note the setting, equipment, and how the patient tolerated the session.
3
A — Assessment
Give your professional interpretation of today, tied to the data above and the goal.
More guidance
Your professional interpretation of today compared with recent sessions and with the goal: whether performance was in line with the last few sessions, better or worse, and what may account for the difference, such as poor sleep or a new medicine. Tie every statement to the data above. If you need another team member's view, say so and add it to the handover table.
4
P — Plan
State next session's plan, then practice set between sessions and who supervises it.
More guidance
State what happens next session and whether anything changes: progression, a new activity, a different time of day, or a co-treatment. Then record practice set for between sessions, who will supervise it, and how it was taught, for example shown and practised, written in the home programme, or filmed on the family's phone with the patient's agreement.
5
Handover to the Team
List only what nursing, other therapists or family must do differently, one action per line.
More guidance
Use this only for things someone else must do differently. Nursing may need a changed transfer method; another therapist may need to know about pain today; the family may need to know which practice to do this evening. Keep each line to one action. A change to precautions follows the clinic's own process, and the handover records that it was followed.
Rehabilitation SOAP note template and example: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
S — Subjective
Mr R. said he slept badly and his “legs feel heavy today”. Night nurse reported he used the commode twice overnight with standby help and no near-falls.
O — Objective
Goal 1 | Sit-to-stand from ward bed, then walk to bathroom door (8 m) with walker | 4 stands: standby help on 3, light hand at hips on 1; walked 8 m twice with one seated rest | Slower on second walk; said legs felt heavy.
P — Plan
Next: repeat sit-to-stand practice at 10 am, when he is less tired. Wife shown how to stand by on his left for the walk to the bathroom; she practised twice with the OT watching.
Handover to the Team
Nursing: from tonight, standby help only for bed-to-commode transfer; walker on the left side of the bed. Family: wife to walk with him to the dining table at dinner, standing on his weaker side.
For co-treatment, write one note naming both therapists, and show which discipline led each activity.
Measure in the conditions the goal describes, and say whether you measured on the ward, gym or home.
Record the session language and whether a relative repeated instructions, for example in Kannada.
If the family filmed practice on a phone, note what was filmed and that the patient agreed.
In healhab, clinics keep this as their own session note template, and reviewed notes carry into later progress reports.
Avoid
Writing “tolerated session well” as the whole objective section.
Leaving out the shared goal link, so notes cannot show which goals got therapy time.
Hiding handover items in the assessment paragraph, where nursing staff rarely look.
Copying the previous note forward and changing a few numbers.
About this session note
A rehabilitation SOAP note records one therapy session as Subjective, Objective, Assessment and Plan. This free template is built for rehab teams: the data table links each activity to a shared goal, and a handover section tells nursing, other therapists and the family what changed today. Physiotherapists, OTs, speech therapists and psychologists can all use it.
Each individual or group session on a rehab programme
Co-treatment sessions with two disciplines together
Home or community sessions, such as stair practice
When every note should link to shared goals
Read more
A shared SOAP structure means the evening nurse can open any therapist's note and find the same things in the same place. The same note works as a rehab daily note for physical therapy, occupational therapy, speech or psychology sessions.
It adds two things most SOAP templates leave out: a data table linking each activity to a shared goal, and a handover table for changes others must act on. Write it on the day, ideally straight after the session.
Questions
What is a rehabilitation SOAP note?+
It is a session note in four parts: Subjective (what the patient and carers reported), Objective (what was done and measured), Assessment (the therapist's interpretation) and Plan (what happens next). This rehab version adds shared-goal links and a team handover.
Can every discipline on the team use the same SOAP note?+
Yes. The structure suits physiotherapy, occupational therapy, speech and language therapy and psychology. Each discipline puts its own data in the objective table, and a shared format makes notes easier to read across the team.
What goes in the objective section of a rehab SOAP note?+
Measurable session data: the activity, the shared goal it served, level of assistance, repetitions, distance, time, cues, rest breaks, equipment and setting. Use the same units as the goal plan so progress can be tracked.
How do I write a SOAP note for a co-treatment session?+
Write one note listing both therapists and their disciplines. In the objective table, show which discipline led each activity, and agree who completes the assessment paragraph. Both therapists should check the note.
Is a rehab daily note the same as a SOAP note?+
A daily note can follow any structure, and SOAP is one of the most common. Some centres use a shorter note most days and a full SOAP note at set intervals. Agree one approach across the team.
How long should a rehab SOAP note be?+
Long enough that another clinician could run the next session without asking you anything. For most sessions that is the data table plus a few lines in each section.
Is there a rehab SOAP note example?+
Yes. Each section guide on this page shows a fictional example entry, using initials only. The Assessment section has no example, because that interpretation belongs to the therapist who ran the session.
