Free Physical Therapy Soap Note

Prepared by: [Your Name]

I. Subjective (S)

A. Patient Reported Concerns

• The patient reports mild to moderate pain in the lower back, rating it 4/10 on the pain scale.

• The pain is aggravated by prolonged sitting and bending forward.

• States the pain improves slightly with walking and stretching.

B. Current Functionality

• The patient reports difficulty standing for long periods and performing daily activities like grocery shopping or bending to tie shoes.

• No significant changes in symptoms since the last visit.

II. Objective (O)

A. Observation

B. Range of Motion (ROM)

C. Strength

D. Special Tests

• Positive straight leg raise test on the left at 45°, indicating potential nerve root involvement.

III. Assessment (A)

• The patient demonstrates moderate dysfunction in lumbar mobility, particularly with flexion and extension, likely due to chronic muscle tightness and possible nerve irritation.

• The reported pain level (4/10) and functional limitations indicate progress from previous visits, but more focused strengthening and stretching are needed for further improvement.

• Potential need for further assessment if symptoms persist beyond the current course of therapy.

IV. Plan (P)

A. Short-Term Goals

• Improve lumbar range of motion (ROM) by 10° within 2 weeks.

• Decrease reported pain level to 2/10 with daily stretching and strengthening exercises.

B. Treatment Plan

• Continue with manual therapy to address muscle tightness in the lumbar region.

• Begin strengthening exercises for core stabilization (e.g., bridges, planks) and hamstring stretches.

• Reassess functional mobility at the next session to adjust the treatment plan if necessary.

C. Patient Education

• Instruct patient on proper posture while sitting and standing to reduce strain on the lumbar spine.

• Recommend a home exercise program including daily stretches for the lower back and hamstrings.

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