Free Physical Therapy Soap Note Template

Physical Therapy Soap Note

Prepared by: [Your Name]

The patient reports mild to moderate pain in the lower back, rating it 4/10 on the pain scale.
The pain is aggravated by prolonged sitting and bending forward.
States the pain improves slightly with walking and stretching.

The patient reports difficulty standing for long periods and performing daily activities like grocery shopping or bending to tie shoes.
No significant changes in symptoms since the last visit.

Observation	Details
Posture	Slight forward flexion was noted in the lumbar spine during standing
Gait	Normal with slight favoring of the left leg

Muscle Group	Strength Rating
Lumbar extensors	4/5
Left hamstring	4/5

Positive straight leg raise test on the left at 45°, indicating potential nerve root involvement.

The patient demonstrates moderate dysfunction in lumbar mobility, particularly with flexion and extension, likely due to chronic muscle tightness and possible nerve irritation.
The reported pain level (4/10) and functional limitations indicate progress from previous visits, but more focused strengthening and stretching are needed for further improvement.
Potential need for further assessment if symptoms persist beyond the current course of therapy.

Improve lumbar range of motion (ROM) by 10° within 2 weeks.
Decrease reported pain level to 2/10 with daily stretching and strengthening exercises.

Continue with manual therapy to address muscle tightness in the lumbar region.
Begin strengthening exercises for core stabilization (e.g., bridges, planks) and hamstring stretches.
Reassess functional mobility at the next session to adjust the treatment plan if necessary.

Instruct patient on proper posture while sitting and standing to reduce strain on the lumbar spine.
Recommend a home exercise program including daily stretches for the lower back and hamstrings.