SOAP Charting System • v3.8
Patient Information
📋
Initial Eval
🔄
Follow-up
Cause of Injury
Treating Therapist
Session Duration (8-Minute Rule)
Select based on physician referral body zones
Single Body Zone
30 min
Dual Body Zone
60 min
S - Subjective
Pain Levels (0-10)
Tension Levels (0-10)
Resting muscle tension separate from pain
Pain History Since Last Visit
Symptom Locations
As per diagnosis or condition
Specific Symptoms
Click a symptom to add severity & frequency details
With Radiating Pain To
Aggravating Factors
Relieving Factors
Additional Patient Statements
Activities, observations, and other patient-reported information
Additional Notes
O - Objective
Visual Observations
Gait
Posture
Restricted Movement
Swelling
Range of Motion Testing (Intake)
Restricted ROM (quick select)
Palpatory Examination
A - Assessment
Diagnosis (ICD-10)
Post-Treatment Pain
Post-Treatment ROM Assessment
Compare post-treatment ROM to intake measurements
Functional Outcomes
Clinical Opinion
P - Plan
Evaluation Type
97161
Full Evaluation
97164
Re-evaluation
Treatment Procedures (CPT) with Time
Select procedures and assign time per 8-minute rule
Total Treatment Time
15 min
Regions Treated
Treatment Goals
Treatment Objectives
Exercises Demonstrated
Treatment Plan
☐Patient referred back to physician
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