SOAP is the world's most widely used physiotherapy note standard — Subjective, Objective, Assessment, Plan. In this article we walk through the structure, a ready-to-use example, and how an AI generator builds a SOAP note from a transcription of your patient conversation.
What is a SOAP note
SOAP is a four-part clinical note structure that organises information from the most subjective (the patient's account) to the most operational (the treatment plan). Used in physiotherapy, general medicine and psychotherapy, it facilitates communication between clinicians and simplifies documentation audits.
The S-O-A-P structure
S — Subjective (Patient history / subjective data)
What the patient says: description of complaints, nature of pain, aggravating and relieving factors, injury history, expectations.
O — Objective (Examination / objective data)
What you observe and measure: ROM, muscle strength, special tests, palpation, posture, gait.
A — Assessment (Clinical assessment)
Your interpretation: physiotherapy diagnostic hypothesis, prognosis, risk factors.
P — Plan (Treatment plan)
Concrete actions: techniques, visit frequency, home exercises, short- and long-term goals.
Example of a complete SOAP note
S:
Patient (45 y/o) presents with right shoulder pain for 3 weeks, increasing when raising the arm above 90°. Night pain when lying on the affected side. VAS 6/10. Injury related to beach volleyball.
O:
Active flexion ROM 110° with pain, passive 150°. Hawkins-Kennedy test positive. Painful arc 70°–120°. Palpatory tenderness at the greater tuberosity of the humerus.
A:
Clinical features of subacromial impingement; probable supraspinatus tendon irritation.
P:
Manual therapy of the glenohumeral joint, humeral head centring exercises, patient education. Sessions 2× per week for 3 weeks. Short-term goal: VAS ≤ 3 within 2 weeks.
5 most common errors
- Mixing sections — recording therapist observations under "S".
- Missing pain assessment scale (VAS / NPRS).
- Omitting goals — a plan without SMART goals is not a plan.
- Abbreviations without a key — "MT L4" only means something to the author.
- Copying the previous note without updating the assessment.
How the AI generator works
The SOAP note generator in Cora AI is a language model optimised for physiotherapy terminology. It works in three steps:
- Transcription — the patient's and therapist's voices are converted to text with speaker separation.
- Classification — each sentence is assigned to the S, O, A or P section.
- Summarisation — the model produces a concise, clinically readable note, removing repetition and small talk.