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SPRY Scribe uses AI to automate SOAP notes
saving time, ensuring accuracy, and keeping workflows smooth.

Experience it Firsthand

What are SOAP Notes?

Usually, the SOAP format is popular as an outlining tool to record the patient's encounters in various settings such as physical therapy. The acronym S.O.A.P has been adopted to represent a model whereby information on the patient is recorded in four areas: Subjective, Objective, Assessment, and Plan.

Subjective

This section includes the patient's report of his/her signs, symptoms, feelings or concerns. It is the quantitative data that the patient has given directly at that particular instance, which could be in the form of pain, emotional conditions or any other. 

Objective

This is the place where the therapist notes down the behavioral variables including the range of movements, strength, postural tone and other tests conducted.

Assessment

 In this section, the therapist assesses the patient in terms of the subjective and the objective information. This involves an evaluation of whether the patient's condition is degenerating, is stagnant or if the patient is experiencing an improvement. 

Plan

The last part describes the following steps in patients' management; what the patient should expect regarding further treatment purpose, any prescribed exercises that he/she could practice, and any modifications to the care plan to be implemented.

How to Write SOAP Notes

It should be noted that putting down SOAP notes does not have to be a herculean task, especially with a proper format.
The following is a breakdown of each section and an example in rehabilitation therapy. 
Subjective
This part of the assessment is dedicated to the patient’s self-reporting of his or her state of health.
For instance, if a patient with lower back pain attends a session, you may document: Again, the patient manages to put into words; a dull pain in the lower back that constantly bores through the buttock area whenever I stand and becomes bearable when sitting or stretching’.
This part is regarded as a personal experience by the patient and some therapists may wish to use the actual words of the patient for insurance purposes.
Objective
Here you may write down the objective data that you have obtained or your subjective notes about what happened in the session, for instance.
For example: Patient has fairly reduced lumbar flexion with pain at 45 degrees superimposed hamstrings recorded as 3/5, during contractual kilocalories test. 
This section tends to provide figures in an attempt to reconstruct what happened to the patient: the patient’s muscle strength, range of motion, and pain scores. 
Assessment
The assessment combines the qualitative and the quantitative aspects to provide a professional opinion of the patient's status. 
In a rehab therapy context: Hearing/Perception: Patient shows slightly increased range of motion since the last session for lumbar region Patient has no increase of strength in the left hamstring since the last session Pain has been constant, possibly due to nerve impingement.
The patient will be re-evaluated two weeks from now.  This in return gives an overall account of the change or the lack of it in the patient’s condition, if there are any complications or improvements on the detailed diagnosis done.
Plan
This section indicates the future actions or changes which ought to be made to the treatment plan of the patient, or other tests to be conducted. 
For example:  May focus on core stabilization and manual treatment of the lower back Pain: include neural slides if there is suspected nerve entrapment. Re-test the hamstring in two weeks.
With detailed guidelines on the direction of further sessions, the plan provides continuity of care to the patient.

Common SOAP Notes Mistakes Rehab Therapists Make

Even experienced rehab therapists can make common errors when writing SOAP notes. These mistakes can affect the quality of patient documentation, lead to miscommunication between care providers, and even cause issues with insurance compliance.

Being Too Vague in the Subjective Section

One common mistake is failing to capture enough detail from the patient's perspective. For instance, writing "Patient reports pain" is too general. It's crucial to be more specific, including details like the intensity, location, type of pain (sharp, dull), and factors that alleviate or worsen it.
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Tip: Always aim to document the patient's exact words and relevant details that help to build a complete clinical picture.

Not Quantifying Objective Data

The objective section should contain measurable, observable data. A frequent mistake is documenting general observations like "Patient has limited range of motion" without providing precise measurements. This lack of detail can lead to unclear or insufficient documentation.
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Tip: Include specific measurements, such as degrees of movement, muscle strength ratings, or observable changes, such as swelling or redness.

Incomplete or Inaccurate Assessments

Some therapists fail to fully integrate the subjective and objective findings into a meaningful assessment. For instance, simply stating "Patient is improving" does not give enough context. The assessment should reflect the patient's progress, changes in condition, or factors influencing their treatment.
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Tip: Use the assessment section to synthesize the data, identifying trends, risks, and treatment adjustments. Ensure it addresses whether the patient is improving, worsening, or plateauing.

Lack of Specificity in the Plan Section

In the plan section, vague recommendations such as "Continue with exercises" are a missed opportunity to detail a precise course of action. This can result in a lack of clarity for follow-up care.
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Tip: Always provide a specific action plan, including treatment goals, exercise modifications, and timelines for reassessment. For instance, "Increase resistance in shoulder isometrics, reassess range of motion in two weeks."

Failing to Document for Insurance Compliance

Therapists may overlook the importance of documenting information that supports the necessity for ongoing treatment, especially for insurance purposes. Incomplete notes could lead to denied claims.
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Tip: Include evidence of medical necessity in your notes, such as details on the patient's diagnosis, functional limitations, and progress. This supports the rationale for continued care and ensures compliance with insurance requirements.

Writing SOAP Notes Long After Sessions

Delaying note writing until long after the session can lead to forgotten details or rushed documentation. This Affects both the accuracy and completeness of the notes.
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Tip: Try to write your SOAP notes immediately after or between sessions while the details are fresh in your mind. SPRY Scribe can help by reducing note-taking time, allowing you to focus more on patient care and documentation accuracy.

Using SPRY scribe you can achieve
New Level of Simplicity

01. Start Recording


When the session starts you will be able to find the 'Start Recording' button on your SPRY EMR interface. 

02. Real-Time Transcription



When you are engaging your patient in the session, SPRY Scribe types the conversation in real time text with the data being sorted into the right places in the SOAP note.

03. Pause if Needed


In case you need to break the transcription process, you can do it anytime depending on the time you are on during the session, making you the ultimate controller of the transcription process. 

04. Stop and Generate



After completing the session, ensure to click 'Stop Recording', and this brings about the finalization of the SPRY Scribe where it comes up with the complete SOAP note of the session that has been recorded.

05. Review and Edit



 You have the ability to review the pen created note in order to edit it and make some changes if required in order to make all the information within it to be correct and in line with your set guidelines.

06. Send to EMR



Once the SOAP note is finalized, seamlessly send it to the EMR system for secure storage and future reference.

Why Choose SPRY Scribe?

Time Efficiency
Using SOAP in a few minutes is an opportunity to save a lot of time for actual interaction with a patient or even relaxation. 
Accuracy
This means that when the tool is used, the accuracy levels for transcribing and organizing the patient information are very high, thus, the possibility of making mistakes significantly minimized.
Customization
This is still your notes and you remain fully in charge of it. In SPRY Scribe, any amendment or addition 'locks down' the note in real-time and the information provided is always your professional judgment. 
HIPAA Compliance
SPRY Scribe operates in a secure HIPAA conducive environment to protect the dignity of the patients by not exposing their information to unauthorized persons.
Continuous Learning
 Over time the AI becomes smarter as it picks up a pattern of the user and his/her style of note taking.

Don’t just take our word for it

Hear from some of our amazing customers who are building faster.
"SPRY has truly increased my documentation efficiency. The time it used to take to document is now reduced by hours, allowing me to focus on patients more."
Brandon V
"I love how quick and easy SPRY is to use. The documentation process has become so much faster, and I can focus more on the patient instead of paperwork."
Madison A
"SPRY has made documenting so much more efficient, and the autonomy it provides for both clinicians and patients is invaluable. It’s made managing my time much easier."
Maggie W

Frequently asked questions

How to Write a Soap Note for Physical Therapy?
Start with the Subjective (patient-reported issues), Objective (measurable observations), Assessment (analysis of progress), and Plan (treatment strategy). Use clear, concise language and focus on therapy-specific details.
How to Write a Soap Note for Speech Therapy?
Document the patient's speech concerns (Subjective), therapy observations (Objective), progress or challenges (Assessment), and the proposed treatment plan (Plan). Ensure it’s tailored to speech goals.
Are Soap Notes Legal Documents?
Yes, SOAP notes are considered legal documents. They provide a formal record of patient care and may be used in audits, billing, or legal proceedings
What Goes in the Assessment Part of a Soap Note​?
The assessment includes the therapist's professional evaluation of the patient’s progress, response to therapy, and any changes in the treatment approach.
How to Create an AI Medical Scribe?
An AI medical scribe is built to capture spoken notes during sessions, transcribe them into structured formats, and assist with documentation. It combines speech recognition with intelligent algorithms to streamline the process.
What Are Some Best Physical Therapy Soap Note Example?
Effective examples include notes with clear Subjective details (patient input), measurable Objective data (e.g., ROM tests), a concise Assessment, and actionable Plans for the next steps.
SPRY has signed the American Physical Therapy Association Digital Transparency pledge,
illustrating our commitment to the fact that digital "physical therapy" services are only performed or directed by licensed physical therapists in accordance with all regulations and APTA’s Standards of Practice for Physical Therapy.

Need help?
SPRY’s got your back.

What is an AI progress note generator?
An AI progress note generator is a tool that helps therapists and mental health professionals create accurate and structured progress notes quickly. It uses AI to streamline documentation, ensuring compliance with industry standards like SOAP and DAP formats.
How does an AI therapy note generator work?
An AI therapy note generator analyzes session details and generates comprehensive notes based on SOAP, DAP, or physical Therapy note formats. It saves time and reduces manual effort while improving accuracy.
Is your AI SOAP note generator HIPAA compliant?
Yes, our AI SOAP note generator is HIPAA-compliant, ensuring the security and confidentiality of patient data. We prioritize privacy and adhere to strict compliance standards for mental health documentation.
Can I use a free AI progress note generator?
Yes! We offer a free AI progress note generator to help therapists and healthcare professionals streamline their workflow. You can try it at no cost and upgrade for advanced features.
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