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Never paste PHI into Claude — Before submitting any prompt, replace all patient-identifying information (name, DOB, MRN, address) with generic placeholders. Claude is not a HIPAA-covered entity, so treat every prompt as if it could be read publicly. Use your EMR for final documentation and only use Claude for draft generation with de-identified data.
Include specific measurements, not summaries — Typing "ROM improved" gives Claude nothing to work with. Typing "shoulder flexion AROM 92 degrees, up from 78 degrees 3 weeks ago" produces a note that reads like a clinician wrote it and satisfies payer scrutiny.
Match your payer's documentation expectations — Medicare, commercial payers, and workers' comp each have different documentation thresholds. Add a line to any prompt like "This patient has [Medicare / BCBS / WC] coverage — emphasize functional necessity language" to get output tailored to that payer's review criteria.
Always review for clinical accuracy before signing — Claude can produce plausible-sounding clinical language that is factually wrong for your patient. Check every measurement, goal status, and intervention detail against your actual session data before pasting into your EMR. You are the clinician of record.
Build a personal prompt library in your workflow — Save your most-used prompts with your typical diagnosis-specific fields pre-filled. For example, keep a "post-TKA daily note" template and a "rotator cuff eval" template so you only need to update the session-specific measurements each time.
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5 Claude Prompts for SOAP Notes — Physical Therapists
Ready-to-use Claude prompts for drafting SOAP notes, initial evaluations, and discharge summaries that save hours of after-session charting.
Why Use AI for SOAP Notes?
Documentation is one of the biggest time burdens in outpatient and inpatient physical therapy. The average clinician spends 30-45 minutes after-hours each day completing SOAP notes, initial evaluations, and discharge summaries. That time adds up quickly, contributing to burnout and cutting into the hours you could spend on direct patient care or professional development.
Claude can dramatically reduce charting time by transforming your raw session observations and measurements into structured, payer-ready SOAP notes. Instead of staring at a blank text box in your EMR, you feed Claude the clinical facts and it produces a well-organized draft that follows standard SOAP formatting conventions. You still review, edit, and sign off on every note — the AI simply removes the blank-page problem and handles the narrative structure for you.
These five prompts cover the documentation scenarios PTs encounter most frequently: daily treatment notes, initial evaluations, discharge summaries, re-evaluation progress notes, and group therapy sessions. Each prompt is built around the kind of shorthand you already use — just fill in the bracketed fields with your session data and paste the prompt into Claude.
The Prompts
Prompt 1: Daily SOAP Note from Session Observations
Use this after a standard treatment session to generate a complete SOAP note draft.
You are a physical therapy documentation specialist. Draft a SOAP note for a PT treatment session using the details below. Use standard SOAP format with clearly labeled Subjective, Objective, Assessment, and Plan sections.
Patient context:
- Diagnosis: [e.g., L4-L5 lumbar disc herniation]
- Visit number: [e.g., 8 of 20 authorized]
- Treatment setting: [outpatient / inpatient / home health / SNF]
Subjective:
- Patient-reported pain level: [X/10, location, quality]
- Functional complaint today: [e.g., "still can't sit at my desk for more than 20 minutes"]
- Changes since last visit: [better / worse / unchanged, specific details]
Objective:
- Interventions performed: [e.g., manual therapy lumbar spine 15 min, therapeutic exercise 25 min, neuromuscular re-education 10 min]
- Key measurements: [e.g., SLR improved to 65 degrees R, lumbar AROM flexion 60%]
- Functional observations: [e.g., sit-to-stand without UE support x3, gait without deviation]
Assessment:
- Overall status: [improving / plateaued / regressed]
- Functional progress toward goals: [briefly note 1-2 goals and status]
Plan:
- Next visit frequency: [e.g., 2x/week]
- Focus for next session: [e.g., progress core stabilization, add standing balance work]
- Any referrals or communications: [e.g., plan to update PCP, ortho follow-up pending]
Instructions:
- Use concise clinical language appropriate for payer review
- Include CPT-relevant detail for each intervention (time, focus area)
- Keep the note under 300 words
- Do NOT fabricate any measurements or patient statementsExample Output:
Subjective: Patient reports current pain at 4/10 in the low back with radiation into the R posterior thigh, described as a dull ache worsening with prolonged sitting. States, "I still can't sit at my desk for more than 20 minutes before the pain starts up." Reports slight improvement in morning stiffness since last visit.
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Objective: Manual therapy to lumbar spine (L4-L5 segment focus, soft tissue mobilization and joint mobilization Grade III) x 15 min. Therapeutic exercise (core stabilization, prone press-ups, supine bridging progression) x 25 min. Neuromuscular re-education (diaphragmatic breathing with pelvic floor coordination) x 10 min. SLR improved to 65 degrees R (previously 55 degrees). Lumbar AROM flexion approximately 60% of normal. Patient performed sit-to-stand without UE support x3, gait observed without antalgic deviation.
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Assessment: Patient is improving. Progressing toward STG of sitting tolerance to 30 minutes (currently 20 min) and LTG of return to full-time desk work without symptom flare. Functional mobility gains noted with reduced compensatory movement patterns.
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Plan: Continue PT 2x/week. Next session: progress core stabilization to anti-rotation exercises, introduce standing balance work on unstable surface. Plan to update PCP regarding functional progress; ortho follow-up pending MRI review.
Prompt 2: Initial Evaluation Documentation
For comprehensive day-one evaluations that establish medical necessity.
You are a physical therapy documentation specialist. Write a comprehensive initial evaluation note from the following examination findings. The note must clearly establish medical necessity for skilled physical therapy.
Patient demographics:
- Age: [X] | Sex: [M/F] | Referral source: [physician name, specialty]
- Primary diagnosis: [ICD-10 code and description]
- Relevant medical history: [list pertinent conditions, surgeries, medications]
- Prior level of function: [e.g., independent community ambulator, full-time desk worker]
Examination findings:
- AROM/PROM: [list affected joints and measurements]
- Strength (MMT): [list key muscle groups and grades]
- Special tests: [list tests performed and results, e.g., Neer's positive R]
- Palpation findings: [e.g., tenderness over R supraspinatus, trigger point upper trapezius]
- Functional limitations: [e.g., cannot reach overhead, unable to lift >10 lbs, Oswestry score 48%]
- Gait/balance observations: [if applicable]
- Standardized outcome measure: [tool name and score, e.g., LEFS 38/80]
Instructions:
- Organize into History, Systems Review, Tests & Measures, Assessment, and Plan of Care sections
- Write 2-3 SMART functional goals with target timeframes
- Include recommended visit frequency and duration (e.g., 2x/week for 8 weeks)
- Emphasize why skilled PT intervention is necessary vs. a home program alone
- Use objective, measurable language throughoutExample Output:
History: 52-year-old female referred by Dr. Patel (orthopedics) for R shoulder pain and functional limitation. Diagnosis: R shoulder impingement syndrome (M75.11). PMH includes hypothyroidism and hypertension, managed with levothyroxine and lisinopril. No prior shoulder surgery. Prior level of function: independent community ambulator, full-time administrative assistant requiring frequent overhead filing and computer work.
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Systems Review: Cardiovascular and pulmonary WNL. Integumentary intact. Musculoskeletal impairments noted in R UE. Communication and cognition intact.
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Tests & Measures: R shoulder AROM: flexion 128 degrees, abduction 115 degrees, IR 45 degrees, ER 62 degrees. PROM: flexion 142 degrees, abduction 130 degrees. MMT: supraspinatus 3+/5, infraspinatus 3/5, middle deltoid 4-/5. Special tests: Neer's positive R, Hawkins-Kennedy positive R, Empty Can 3+/5 with pain. Palpation: tenderness over R supraspinatus tendon and trigger point in R upper trapezius. DASH score: 58/100. Patient unable to reach overhead, cannot lift greater than 10 lbs at or above shoulder height.
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Assessment: Patient presents with significant R shoulder impairment limiting overhead reaching, lifting, and sustained computer work. Deficits in rotator cuff strength, scapular stability, and glenohumeral mobility require skilled PT intervention to restore pain-free functional use. A home program alone is insufficient due to the need for manual therapy, progressive rotator cuff loading, and neuromuscular re-education of scapulohumeral rhythm.
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Plan of Care: Frequency: 2x/week for 8 weeks (16 visits). Goals: (1) R shoulder flexion AROM to 160 degrees within 4 weeks. (2) Patient will independently lift 15 lbs overhead without pain within 8 weeks. (3) DASH score to 30/100 or below within 8 weeks.
Prompt 3: Discharge Summary from Treatment Data
For closing out an episode of care with a clear outcome narrative.
You are a physical therapy documentation specialist. Write a discharge summary that documents the full episode of care and functional outcomes achieved.
Episode overview:
- Diagnosis: [e.g., R rotator cuff repair, post-op]
- Total visits attended: [X of Y authorized]
- Date range: [start date] to [discharge date]
- Discharge reason: [goals met / insurance exhausted / patient self-discharged / physician order]
Baseline vs. discharge comparison:
- Pain: [initial X/10] → [discharge X/10]
- ROM: [e.g., shoulder flexion 90° → 165°]
- Strength: [e.g., shoulder ER 3/5 → 4+/5]
- Functional measure: [e.g., DASH score 72 → 28]
- Functional milestones: [e.g., returned to overhead reaching, resumed gym workouts]
Goals status:
- [Goal 1]: [met / partially met / not met]
- [Goal 2]: [met / partially met / not met]
- [Goal 3]: [met / partially met / not met]
Instructions:
- Summarize the treatment approach in 2-3 sentences
- Present outcomes using side-by-side baseline vs. discharge data
- Note any goals not met and the clinical reasoning
- Include a home exercise program status and follow-up recommendations
- Keep under 250 wordsExample Output:
Discharge Summary: Patient was seen for R rotator cuff repair (post-op arthroscopic supraspinatus repair) over 18 visits from 01/06/2026 to 03/27/2026. Discharge reason: goals met.
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Treatment Approach: Plan of care focused on progressive ROM restoration, rotator cuff and scapular strengthening, and return to functional overhead activities. Interventions included manual therapy, therapeutic exercise, neuromuscular re-education, and a structured HEP progression.
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Outcomes — Baseline vs. Discharge:
Pain: 7/10 at rest, 9/10 with movement → 1/10 at rest, 2/10 with resisted activity. R shoulder flexion AROM: 90 degrees → 165 degrees. R shoulder ER AROM at 90 degrees abduction: 38 degrees → 78 degrees. Shoulder ER strength: 3/5 → 4+/5. DASH score: 72 → 28. Functional milestones: patient returned to overhead reaching, resumed independent gym workouts including lat pulldowns and dumbbell press at moderate load.
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Goals Status: (1) Achieve shoulder flexion AROM to 160 degrees — met (165 degrees). (2) Independently perform overhead lifting of 20 lbs without pain — met. (3) Return to gym routine at pre-surgical intensity — partially met; patient performing at approximately 85% of prior load without symptoms and continuing to progress independently.
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Recommendations: Patient discharged with updated 5-exercise HEP emphasizing continued rotator cuff endurance and scapular control. Advised gradual return to full loading over 4 weeks. Follow-up with Dr. Reeves (orthopedics) scheduled for 04/10/2026. No further skilled PT indicated at this time.
Prompt 4: Re-Evaluation Progress Note
For mid-episode progress updates that justify continued care.
You are a physical therapy documentation specialist. Write a re-evaluation progress note that justifies continued skilled physical therapy services.
Patient context:
- Diagnosis: [e.g., post-TKA L knee, 6 weeks post-op]
- Current visit: [X of Y authorized]
- Re-evaluation reason: [scheduled progress check / insurance re-authorization / plan update]
Progress since initial evaluation or last re-eval:
- Pain: [initial X/10] → [current X/10]
- ROM changes: [e.g., knee flexion 78° → 108°]
- Strength changes: [e.g., quad strength 2+/5 → 3+/5]
- Functional outcome measure: [e.g., TUG improved from 24s to 14s]
- Functional gains: [e.g., now ascending stairs step-over-step with rail]
Remaining deficits:
- [e.g., knee flexion still 17° below WFL for stair descent]
- [e.g., unable to tolerate standing >20 min for work tasks]
Updated goals: [list 2-3 revised SMART goals]
Revised plan: [any changes to frequency, interventions, or focus]
Instructions:
- Clearly document measurable progress from prior data points
- Articulate remaining functional deficits that require skilled intervention
- Justify why the patient has not yet reached a maintenance level
- Use language aligned with Medicare/payer medical necessity standards
- Keep under 300 wordsExample Output:
Re-Evaluation Progress Note: Patient is a 64-year-old male, 6 weeks post L total knee arthroplasty, currently visit 10 of 20 authorized. Re-evaluation performed for scheduled progress check and insurance re-authorization.
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Progress Since Initial Evaluation: Pain decreased from 7/10 to 3/10 at rest, 5/10 with activity. L knee flexion ROM improved from 78 degrees to 108 degrees. L knee extension deficit reduced from -8 degrees to -2 degrees. L quad strength improved from 2+/5 to 3+/5. Timed Up and Go improved from 24 seconds to 14 seconds. Patient now ascending stairs step-over-step with rail (previously step-to pattern bilateral rails). Independent with household ambulation without assistive device.
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Remaining Deficits: L knee flexion remains 17 degrees below WFL for reciprocal stair descent and safe floor-to-stand transfers. Patient unable to tolerate standing greater than 20 minutes, insufficient for return to part-time retail position requiring 4-hour standing shifts. Quad strength remains below functional threshold for single-leg stance activities.
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Updated Goals: (1) L knee flexion to 125 degrees within 4 weeks. (2) Patient will tolerate standing for 30 minutes continuously within 4 weeks. (3) TUG to less than 10 seconds within 4 weeks.
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Revised Plan: Continue PT 2x/week. Progress closed-chain strengthening with emphasis on eccentric quad loading. Add prolonged standing tolerance training and work simulation tasks. Patient has not reached maintenance level; continued skilled PT is required to address ROM, strength, and functional deficits that limit safe community mobility and return to work.
Prompt 5: Group Therapy Session Note
For documenting individual patient participation within a group treatment format.
You are a physical therapy documentation specialist. Write an individualized SOAP note for a patient who participated in a group therapy session. The note must document this specific patient's individual response and progress, not just the group activity.
Session context:
- Group format: [e.g., balance and fall prevention class, 4 patients, 1 PT]
- Session duration: [e.g., 45 minutes]
- CPT code basis: [e.g., 97150 — group therapeutic procedures]
Patient-specific information:
- Patient diagnosis: [e.g., Parkinson's disease, Hoehn & Yahr stage 2]
- Individual goals addressed: [e.g., improve dynamic standing balance, reduce fall risk]
Subjective:
- Patient report: [e.g., "I feel steadier this week but still nervous turning around"]
Objective:
- Activities performed: [e.g., tandem stance holds, reactive stepping drills, multi-directional reaching]
- Individual performance: [e.g., tandem stance 18s (up from 12s last week), 2 loss-of-balance episodes during reactive stepping]
- Cues/assistance required: [e.g., verbal cues for posture, standby assist for lateral stepping]
Assessment: [e.g., improving static balance, dynamic balance remains impaired]
Plan: [e.g., continue group 1x/week, add individual session for gait training]
Instructions:
- Emphasize the individual patient's performance, not group-level activity
- Document how group participation addresses this patient's specific goals
- Include measurable data points for this patient
- Keep under 200 wordsExample Output:
Subjective: Patient reports, "I feel steadier this week but still nervous turning around." Denies any falls since last session. States balance confidence is gradually improving during daily activities at home.
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Objective: Patient participated in group balance and fall prevention class (4 patients, 1 PT, 45 min, CPT 97150). Activities included tandem stance holds, reactive stepping drills, and multi-directional reaching tasks. Individual performance: tandem stance hold 18 seconds (up from 12 seconds last week). Two loss-of-balance episodes observed during reactive lateral stepping drills, recovered independently. Required verbal cues for upright posture during reaching tasks and standby assist for lateral stepping. Maintained appropriate BOS during multi-directional reaching without stepping strategy in 7 of 10 trials.
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Assessment: Patient demonstrates improving static standing balance as evidenced by tandem stance gains. Dynamic balance remains impaired, particularly with lateral weight shifts and reactive responses, consistent with Parkinson's-related postural instability. Group setting provides appropriate challenge through unpredictable movement demands that address fall risk reduction goals.
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Plan: Continue group balance class 1x/week. Add individual PT session 1x/week to address gait training with emphasis on turning, dual-task walking, and community ambulation safety. Reassess Berg Balance Scale in 2 weeks.