Most documentation guidance answers the question *what sections should a note have*. That is the easy half. The harder question — the one that decides whether a record is any use six weeks later — is **which fields make a measurement repeatable**.
SOAP is a container, not a method
Subjective, Objective, Assessment, Plan is the standard structure and there is no reason to abandon it. But SOAP tells you *where* to put information, not *what* to put there. Two clinicians can both write a complete SOAP note and only one of them can reproduce their own measurement a month later.
| Section | Commonly written | What makes it reusable |
|---|---|---|
| Subjective | Patient reports pain in right shoulder | Onset, aggravating and easing factors, and the activity the patient names as most limited |
| Objective | Shoulder flexion limited | Right 130°, left 165°, active, seated, measured at the lateral midline |
| Assessment | Rotator cuff irritation | Which findings support it and which do not; what would change the interpretation |
| Plan | Exercises given | Goals expressed in the same units as the measurements, and the date of re-assessment |
The right-hand column is not longer for its own sake. Each addition answers a question the next reader will otherwise have to guess.
Findings and interpretation are different things
This is the single most common failure in assessment records. *“Right shoulder flexion 130°”* is a finding. *“Restricted right shoulder”* is an interpretation. When both live in the same sentence, a later reader cannot tell what was measured from what was concluded — and if the interpretation turns out to be wrong, the measurement is discredited along with it.
Keeping them apart costs nothing at the time of writing and protects the record permanently. It also makes handover possible: another clinician can accept your findings while forming their own interpretation.
The fields that make a measurement comparable
A number on its own carries almost no information. These are the fields that turn it into something you can compare against:
- **Side.** Obvious, routinely omitted, and fatal to any comparison when missing.
- **Active or passive.** An active value compared against a passive one is not a comparison at all.
- **Patient position.** Hip flexion measured supine and seated are different measurements of the same joint.
- **Landmarks used.** Which anatomical points the axis and arms were aligned to.
- **Date and time context.** Morning versus evening, and before or after exercise, both move the number in painful presentations.
- **Who measured.** Observational ratings vary between raters; knowing the rater is part of reading the value.
Documenting for three different readers
The same assessment is read by three people with different needs, and trying to serve all three in one document usually serves none of them well.
| Reader | Question they arrive with | What they need from the record |
|---|---|---|
| You, next session | What did I measure, and how? | Full measurement conditions |
| Another clinician | Where is this patient, and what was done? | Findings and reasoning, separately stated |
| The patient | Am I improving? | Two values side by side, in plain language |
The workable solution is not a compromise document but **two outputs from one dataset**: the clinical record keeps its detail, the patient copy is reduced to what changed and what comes next.
Why templates are not enough
A form template standardises which boxes exist. It does not make the values inside them comparable over time, because a filled form is a document — and a folder of documents is not a measurement history. Seeing change across six sessions means opening six files and comparing them by hand.
Structured storage solves a different problem from templates: values recorded as data can be placed side by side, charted, and carried into a report automatically. The document is then generated *from* the data rather than being the data.
DeepClinic stores measurement history and produces comparative PDF reports from it. For how the measurement itself should be taken, see Range of Motion Measurement.
Common documentation errors
- Recording a value without the side or the position it was taken in.
- Merging a finding and an interpretation into one sentence.
- Writing goals in language that cannot be checked against a measurement.
- Documenting the initial assessment thoroughly and the re-assessments briefly — which removes the point of the baseline.
- Giving the patient the clinical record unchanged and expecting it to inform them.
- What should a physiotherapy assessment record include?
- Subjective history, objective measurements with their conditions, the clinical interpretation stated separately from the findings, and a plan with measurable goals and a re-assessment date. Every measurement should carry its side, position, active or passive status and the landmarks used.
- How do you write an assessment in physiotherapy?
- State the findings first, each with its measurement conditions — side, position, active or passive, landmarks. Then write the reasoning separately, naming which findings support it and which do not. Finish with goals expressed in the same units as the measurements and a date for re-measurement.
- Is SOAP still the standard for physiotherapy notes?
- SOAP remains the common structure and works well as a container. It defines where information goes but not what detail each entry needs; the detail is what makes a record reusable, and it has to be added deliberately.
- How do I keep findings separate from interpretation?
- State the measurement first, in its own sentence, with units and conditions. Put the reasoning in the assessment section and make clear which findings support it. If a later reader cannot tell what was measured from what was concluded, the two have been merged.
- Are assessment templates enough for tracking progress?
- Templates standardise which fields are captured but do not make values comparable over time. Tracking requires the values to be stored as structured data so two dates can be placed side by side; a document is a snapshot of that data, not a substitute for it.
- Should the patient receive the same document as the clinical record?
- They should come from the same data but not at the same level of detail. The clinical record preserves measurement conditions; the patient copy shows what was measured, what changed and what happens next, in language they can act on.
Sources
- World Physiotherapy — professional standards and record keeping principles
- Magee DJ. Orthopedic Physical Assessment. Elsevier — recording and interpreting assessment findings.
- WHO — International Classification of Functioning, Disability and Health (ICF)