What is SOAP note?
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A SOAP note is a clinical record structured into four sections: Subjective (what the patient reports), Objective (what you measure and observe), Assessment (your clinical reasoning and diagnosis), and Plan (treatment, advice and follow-up). It's the dominant note format in UK physiotherapy and allied health practice.
The format's value is that it forces the record to show reasoning, not just findings — the Assessment section is where a defensible note differs from a list of measurements. UK professional bodies don't mandate SOAP specifically, but their record-keeping standards (CSP guidance, HCPC standards) require exactly what a good SOAP note demonstrates: enough detail for another clinician to take over, and reasoning that justifies the plan.
- Subjective: presenting complaint, history, patient-reported symptoms, aggravating and easing factors.
- Objective: examination findings, range of movement, strength, special tests, outcome measures.
- Assessment: clinical impression, differential diagnosis, progress against the plan — the reasoning.
- Plan: treatment delivered, exercises prescribed, advice given, and what happens next.
The practical problem is volume: a full diary means a dozen or more SOAP notes a day, and the Assessment section — the part that matters most — is the part most often thinned by time pressure. This is the workload AI scribes were built for: drafting the full structure from the consultation, with the clinician reviewing and signing.