What the SOAP Note Generator actually produces

SOAP NOTE - Physical Therapy Session 6 of 12 | Follow-up Visit Diagnosis: Lumbar disc herniation with radiculopathy (L4-L5), ICD-10: M51.16 SUBJECTIVE: Patient is a 42-year-old male presenting for follow-up physical therapy. Current low back pain rated 4/10, demonstrating improvement from 7/10 at initial evaluation. Patient reports sharp, shooting pain radiating down the left leg to the knee level, particularly with prolonged sitting exceeding 30 minutes. Reports difficulty sleeping on the left side. Denies bowel or bladder dysfunction. Notes positive response to home exercise program, specifically citing benefit from prone press-ups performed between sessions. Patient works a desk job requiring approximately 8 hours of daily sitting. OBJECTIVE: Posture: Forward head posture noted; mild lumbar flexion bias observed in standing. Range of Motion: Lumbar flexion 60° (within normal limits); lumbar extension 15° (limited, reproduces left lower extremity pain at end range); lateral flexion right 25°, left 20°. Neurological: Sensation intact to light touch bilateral lower extremities. Straight leg raise positive on left at 45°, negative on right. Strength: Left hip abductor 4/5 (MMT); left knee extensor 4-/5 (MMT). Palpation: Tenderness noted over L4-L5 paraspinals and left sacroiliac joint region. Special Tests: FAIR test negative bilaterally. Gait: Antalgic pattern noted, favoring right side. Treatment Rendered: 1. Moist heat application to lumbar spine, 10 minutes pre-treatment 2. Manual therapy: Grade III-IV PA joint mobilizations to L4-L5, 3 sets 3. Mechanical intermittent lumbar traction, 40 lbs, 10 minutes 4. Therapeutic exercise: McGill Big 3 (curl-up, side plank, bird-dog) 3×10 repetitions each; left hip abductor strengthening via clamshells and lateral band walks, 3×15 repetitions 5. Neuromuscular re-education: Pelvic tilt and lumbar stabilization on unstable surface (foam pad), 2×10 repetitions 6. Patient education: Ergonomic desk setup reviewed; lumbar support use encouraged; 30-minute sit-to-stand reminder implemented Patient Tolerance: Patient tolerated all interventions well. Reported immediate post-traction relief with left lower extremity pain reduced to 1/10. Demonstrated improved form on bird-dog exercise compared to prior session. Verbalized understanding of ergonomic modifications. No adverse reactions noted. ASSESSMENT: Patient is a 42-year-old male with lumbar disc herniation and L4-L5 radiculopathy, currently in session 6 of a 12-session course of care. Objective findings demonstrate continued impairment: limited lumbar extension (15°) with pain reproduction; positive straight leg raise on left at 45°; left-sided weakness in hip abductors (4/5) and knee extensors (4-/5); and antalgic gait pattern. These impairments correlate directly with functional limitations: difficulty prolonged sitting (occupational demand of 8 hours/day), sleep disturbance secondary to positional pain, and reduced mobility. Pain reduction from 7/10 to 4/10, combined with improved exercise technique and patient engagement with home program, indicates positive response to treatment. Continued skilled physical therapy is medically necessary to address neuromuscular weakness, restore lumbar stability, normalize gait mechanics, and facilitate return to full-time desk work duties. PLAN: Patient will continue skilled physical therapy 2 times per week for 6 additional weeks (sessions 7-12 of current episode). Short-term goals (4 weeks): reduce low back pain to ≤2/10 at rest; increase lumbar extension ROM to 25°; normalize bilateral straight leg raise to negative. Long-term goals (12 weeks): return to full-time desk work without pain; achieve independent home exercise program compliance; improve left lower extremity strength to 5/5 bilaterally; demonstrate ability to walk 30 minutes continuously without antalgic gait pattern. Planned interventions will continue to include manual therapy (PA mobilizations), mechanical traction as tolerated, progressive strengthening exercises with emphasis on hip abductors and lumbar stabilizers, neuromuscular re-education on dynamic stabilization, and ongoing ergonomic training. Patient education will reinforce sit-to-stand frequency, proper sleeping positions, and early self-management strategies. Re-evaluation will occur at session 9. Patient demonstrates good adherence and motivation; no referrals needed at this time.

Patient is a 42-year-old male with lumbar disc herniation and L4-L5 radiculopathy, currently in session 6 of a 12-session course of care. Objective findings demonstrate continued impairment: limited lumbar extension (15°) with pain reproduction; positive straight leg raise on left at 45°; left-sided weakness in hip abductors (4/5) and knee extensors (4-/5); and antalgic gait pattern. These impairments correlate directly with functional limitations: difficulty prolonged sitting (occupational demand of 8 hours/day), sleep disturbance secondary to positional pain, and reduced mobility. Pain reduction from 7/10 to 4/10, combined with improved exercise technique and patient engagement with home program, indicates positive response to treatment. Continued skilled physical therapy is medically necessary to address neuromuscular weakness, restore lumbar stability, normalize gait mechanics, and facilitate return to full-time desk work duties.

Patient will continue skilled physical therapy 2 times per week for 6 additional weeks (sessions 7-12 of current episode). Short-term goals (4 weeks): reduce low back pain to ≤2/10 at rest; increase lumbar extension ROM to 25°; normalize bilateral straight leg raise to negative. Long-term goals (12 weeks): return to full-time desk work without pain; achieve independent home exercise program compliance; improve left lower extremity strength to 5/5 bilaterally; demonstrate ability to walk 30 minutes continuously without antalgic gait pattern. Planned interventions will continue to include manual therapy (PA mobilizations), mechanical traction as tolerated, progressive strengthening exercises with emphasis on hip abductors and lumbar stabilizers, neuromuscular re-education on dynamic stabilization, and ongoing ergonomic training. Patient education will reinforce sit-to-stand frequency, proper sleeping positions, and early self-management strategies. Re-evaluation will occur at session 9. Patient demonstrates good adherence and motivation; no referrals needed at this time.