Example output · Physical Therapist AI
What the SOAP Note Generator actually produces
Turns your raw session notes (subjective report, objective measurements, treatment given, patient response, goals) into a structured SOAP note with a separate assessment and plan section.
- Diagnosis:
- Postsurgical ACL reconstruction, right knee (S83.511A)
- Session Type:
- Follow-up outpatient PT visit, week 6
- Subjective:
- Patient reports knee feels "more stable" but still stiff in the morning. Rates pain 3/10, up from 2/10 after increasing home exercises. Sleeping better, only waking once due to discomfort.
- Objective:
- AROM 5-110 deg, up from 5-100 last visit. Quad activation improved, minimal extension lag. Gait without assistive device, mild antalgic pattern. Girth measurement 2cm difference from left. Single leg stance 15 sec with mod support.
- Treatment:
- Manual therapy for patellar mobility, quad sets and SLR progression, stationary bike 10 min, balance training on foam pad, gait training with cues for symmetry, cryotherapy post session.
- Patient Response:
- Tolerated session well with mild soreness after bike, reported improved confidence with weight bearing during gait training.
- Goals:
- Achieve full AROM 0-130 deg, independent single leg stance 30 sec, return to jogging program by week 10.
SUBJECTIVE:
Patient is a follow-up outpatient PT visit, week 6 status post right ACL reconstruction (ICD-10 S83.511A [verify code and payer rules]). Patient reports the knee feels "more stable" but continues to note morning stiffness. Pain is rated 3/10, increased from 2/10 at prior visit, which patient attributes to an increase in home exercise volume. Sleep is reported as improved, with only a single nighttime awakening due to discomfort (input-derived; baseline sleep disturbance frequency prior to this visit not provided — verify).
OBJECTIVE:
- AROM (right knee): 5–110 degrees, improved from 5–100 degrees at prior visit (input-derived).
- Strength: Quad activation reported as improved with minimal extension lag noted; formal MMT grades [not provided — verify].
- Special tests: [not provided — verify].
- Gait: Ambulating without assistive device; mild antalgic pattern observed.
- Palpation/Girth: Circumferential girth measurement shows 2 cm difference compared to left lower extremity (input-derived; laterality of greater measurement not specified — verify).
- Functional measures: Single leg stance 15 seconds with moderate support (right lower extremity).
TREATMENT PROVIDED:
Manual therapy for patellar mobility; quad sets and SLR progression; stationary bike x10 minutes; balance training on foam pad; gait training with cues for symmetry; cryotherapy post-session.
PATIENT RESPONSE:
Patient tolerated session well with mild soreness reported after bike use. Patient reported improved confidence with weight-bearing during gait training.
ASSESSMENT:
Patient demonstrates measurable interval progress at week 6 post-ACL reconstruction, evidenced by a 10-degree gain in AROM (100 to 110 degrees), improved quadriceps activation with minimal extension lag, and improved subjective weight-bearing confidence during gait training. These gains are consistent with expected progression of skilled rehabilitation for this diagnosis. However, residual impairments persist, including a 2 cm girth differential compared to the contralateral limb, reduced single leg stance tolerance (15 seconds with moderate support), and a mild antalgic gait pattern, which continue to limit functional weight-bearing tolerance, balance, and dynamic stability. The slight increase in pain (2/10 to 3/10) temporally associated with increased home exercise volume is noted; this should be monitored to ensure appropriate exercise progression without exacerbation of symptoms, per treating clinician judgment. Formal strength grading (MMT) and special test findings were not obtained/provided at this visit and are recommended for a more complete impairment picture — verify. Overall, the patient continues to demonstrate impairments in ROM, strength, balance, and gait mechanics that are directly linked to functional limitations (single leg stance, symmetric gait, weight-bearing tolerance) and support the continued medical necessity of skilled physical therapy intervention at this stage of recovery.
PLAN:
Continue skilled physical therapy at a frequency and duration per the established plan of care [frequency/duration — verify with treating clinician/POC]. Short-term goals include progressing AROM toward functional range, improving single leg stance tolerance with decreased support, and reducing antalgic gait pattern. Long-term goals include achieving full AROM 0–130 degrees, independent single leg stance of 30 seconds, and safe return to a jogging program by week 10, contingent on continued progression of strength, balance, and gait symmetry. Planned interventions include continued manual therapy for patellofemoral mobility, progressive quadriceps and hamstring strengthening, neuromuscular re-education and balance training, gait training for symmetry, and cardiovascular conditioning via stationary bike as tolerated. Home exercise program to be reviewed and adjusted as needed given the reported mild pain increase; patient education on activity pacing to be reinforced. Reassessment of strength via formal MMT and appropriate special testing is recommended at next visit to complete the impairment picture. Continued monitoring of girth measurements for effusion trend is recommended per clinical judgment. No new referrals indicated at this time based on information provided; any change in status (e.g., increased swelling, mechanical instability, or worsening pain) should prompt reassessment and communication with the referring surgeon per facility protocol.
Patient demonstrates measurable interval progress at week 6 post-ACL reconstruction, evidenced by a 10-degree gain in AROM (100 to 110 degrees), improved quadriceps activation with minimal extension lag, and improved subjective weight-bearing confidence during gait training. These gains are consistent with expected progression of skilled rehabilitation for this diagnosis. However, residual impairments persist, including a 2 cm girth differential compared to the contralateral limb, reduced single leg stance tolerance (15 seconds with moderate support), and a mild antalgic gait pattern, which continue to limit functional weight-bearing tolerance, balance, and dynamic stability. The slight increase in pain (2/10 to 3/10) temporally associated with increased home exercise volume is noted; this should be monitored to ensure appropriate exercise progression without exacerbation of symptoms, per treating clinician judgment. Formal strength grading (MMT) and special test findings were not obtained/provided at this visit and are recommended for a more complete impairment picture — verify. Overall, the patient continues to demonstrate impairments in ROM, strength, balance, and gait mechanics that are directly linked to functional limitations (single leg stance, symmetric gait, weight-bearing tolerance) and support the continued medical necessity of skilled physical therapy intervention at this stage of recovery.
Continue skilled physical therapy at a frequency and duration per the established plan of care [frequency/duration — verify with treating clinician/POC]. Short-term goals include progressing AROM toward functional range, improving single leg stance tolerance with decreased support, and reducing antalgic gait pattern. Long-term goals include achieving full AROM 0–130 degrees, independent single leg stance of 30 seconds, and safe return to a jogging program by week 10, contingent on continued progression of strength, balance, and gait symmetry. Planned interventions include continued manual therapy for patellofemoral mobility, progressive quadriceps and hamstring strengthening, neuromuscular re-education and balance training, gait training for symmetry, and cardiovascular conditioning via stationary bike as tolerated. Home exercise program to be reviewed and adjusted as needed given the reported mild pain increase; patient education on activity pacing to be reinforced. Reassessment of strength via formal MMT and appropriate special testing is recommended at next visit to complete the impairment picture. Continued monitoring of girth measurements for effusion trend is recommended per clinical judgment. No new referrals indicated at this time based on information provided; any change in status (e.g., increased swelling, mechanical instability, or worsening pain) should prompt reassessment and communication with the referring surgeon per facility protocol.
Replace the diagnosis, session details, and measurements with your actual patient's data, and confirm the ICD-10 code and plan-of-care frequency/duration match your records before finalizing.
Human review: This is a documentation draft only — the treating clinician must verify all measurements, codes, and clinical judgments before the note is entered into the patient's chart or billed.
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