Orthopedic SOAP Notes (with Examples)

Orthopedic care focuses on bones, joints, muscles, ligaments, and movement. Every orthopedic visit depends on clear and accurate documentation. One of the most trusted and widely used formats for this documentation is the SOAP note. SOAP notes help clinicians organize patient information in a clear and logical way. They also help improve communication between doctors, therapists, nurses, and insurance providers.

An orthopedic SOAP note is not just about pain. It captures how an injury affects movement, strength, daily activities, and recovery progress. Whether the patient has knee pain, back strain, shoulder injury, or joint stiffness, SOAP notes help tell the full clinical story. This guide explains orthopedic SOAP notes step by step, with complete examples.

What Is an Orthopedic SOAP Note?

An orthopedic SOAP note is a structured clinical note used to document problems related to the musculoskeletal system. This includes bones, joints, muscles, tendons, ligaments, and posture. The SOAP format helps clinicians record patient complaints, physical findings, diagnosis, and treatment plans in a consistent way.

SOAP stands for Subjective, Objective, Assessment, and Plan. Each section has a clear role. The Subjective section records what the patient says. The Objective section records what the clinician sees and measures. The Assessment section explains the clinical judgment. The Plan section outlines what will be done next.

In orthopedic care, SOAP notes are especially important because many conditions involve movement, pain levels, physical limitations, and recovery timelines. Clear notes help track progress over time and support clinical decisions, referrals, imaging, and insurance claims.

Why SOAP Notes Are Important in Orthopedic Care

Orthopedic conditions often change slowly and require follow-up visits. SOAP notes allow clinicians to compare current findings with previous visits. This helps determine whether a patient is improving, staying the same, or getting worse. Without good documentation, it becomes difficult to measure recovery or justify changes in treatment.

SOAP notes also protect clinicians legally. Orthopedic injuries can involve work accidents, sports injuries, or long-term disability claims. Clear notes show that proper assessments were done and appropriate care was provided. This is important for audits, insurance reviews, and legal cases.

Finally, SOAP notes improve teamwork. Orthopedic patients are often treated by multiple providers, such as doctors, physical therapists, and orthopedic surgeons. A well-written SOAP note allows every provider to understand the patient’s condition and treatment plan without confusion.

Structure of an Orthopedic SOAP Note

An orthopedic SOAP note follows the same four-part structure as any other SOAP note, but the content focuses on musculoskeletal findings. Each section builds on the previous one and should be written in clear and simple language.

The goal is not to use complex medical terms, but to clearly explain what is happening with the patient’s body. Each section should be complete, detailed, and easy to understand.

Subjective (S) – Orthopedic SOAP Note

The Subjective section records the patient’s own words. It describes pain, discomfort, stiffness, weakness, or difficulty moving. This section does not include test results or clinician opinions. It only reflects what the patient reports.

In orthopedic cases, patients often describe pain location, pain type, severity, timing, and triggers. They may also explain how the problem affects walking, lifting, sleeping, or daily tasks. Past injuries, surgeries, and treatments should also be included when relevant.

A strong Subjective section gives context to the physical exam. It helps the clinician understand how the condition affects the patient’s life and guides what to examine during the visit.

What to include in Orthopedic Subjective notes:

• Location of pain or discomfort
• Pain severity (usually 0–10 scale)
• Pain type (sharp, dull, aching, burning, stiffness)
• Onset and duration
• Activities that worsen or improve symptoms
• Functional limits (walking, lifting, sitting, standing)
• Previous injuries or treatments

Objective (O) – Orthopedic SOAP Note

The Objective section includes measurable and observable findings. This is where the clinician documents what they see, feel, and measure during the exam. In orthopedic care, this section is often very detailed.

Objective data may include range of motion, swelling, tenderness, muscle strength, posture, gait, reflexes, and special test results. Vital signs and imaging results may also be included if available.

This section should be factual and free from opinions. Measurements should be exact whenever possible. Clear objective data supports diagnosis, treatment planning, and progress tracking.

What to include in Orthopedic Objective notes:

• Range of motion (limited or full)
• Swelling, redness, bruising
• Tenderness on palpation
• Muscle strength grading
• Gait or posture abnormalities
• Special orthopedic test results
• Imaging findings (if available)

Assessment (A) – Orthopedic SOAP Note

The Assessment section explains the clinician’s interpretation of the findings. This is where the diagnosis or working diagnosis is recorded. It connects the Subjective complaints with the Objective findings.

In orthopedic care, the Assessment may include specific diagnoses like muscle strain, ligament sprain, tendinitis, arthritis, or suspected disc issues. It may also note the severity, stage, or progression of the condition.

This section should be clear and concise, but still detailed enough to explain the clinical reasoning. If the diagnosis is not confirmed, the Assessment can list likely conditions.

Plan (P) – Orthopedic SOAP Note

The Plan section outlines the next steps in care. It explains what treatments, tests, referrals, or follow-ups are planned. This section should be practical and easy to follow.

Orthopedic plans often include pain management, physical therapy, exercises, imaging, activity modification, and follow-up visits. Patient education is also an important part of the plan.

A good Plan section shows that care is organized and intentional. It helps both the patient and other providers understand what comes next.

What to include in Orthopedic Plan notes:

• Medications or pain management
• Physical therapy or exercises
• Imaging or lab orders
• Activity restrictions
• Referrals to specialists
• Follow-up schedule

Orthopedic SOAP Note Examples

Below are four orthopedic SOAP note examples:

Knee Pain (Possible Meniscus Injury)

Subjective (S)

The patient reports pain in the right knee for the past three weeks. The pain started after the patient twisted the knee while playing football with friends. The patient describes the pain as sharp and deep inside the knee joint. Pain is rated 6 out of 10 while walking and increases to 8 out of 10 when squatting or climbing stairs. The patient also reports stiffness in the knee, especially in the morning, and notices a clicking or catching sensation when bending the knee.

The patient says the knee feels unstable at times, as if it might give way. Rest helps reduce the pain, but activity makes it worse. The patient denies numbness, tingling, or pain radiating to the leg or foot. There is no history of previous knee surgery, but the patient reports mild knee pain in the past after sports activities that resolved on its own.

Objective (O)

On examination, the right knee shows mild swelling compared to the left knee. There is tenderness along the medial joint line on palpation. Range of motion is reduced, with pain noted during knee flexion beyond 90 degrees. Extension is nearly full but causes discomfort at the end range. The McMurray test is positive on the right knee, producing pain and a clicking sensation.

Gait assessment shows a mild antalgic gait, with the patient favoring the right leg. No redness or increased warmth is observed. Muscle strength in the right lower extremity is slightly reduced at 4/5 due to pain. Sensation is intact, and distal pulses are normal.

Assessment (A)

Right knee pain, likely due to a medial meniscus injury. The patient’s history of twisting injury, joint line tenderness, mechanical symptoms, and positive McMurray test support this assessment.

Plan (P)

Order an MRI of the right knee to confirm the presence and extent of meniscal injury. Advise the patient to rest the knee and avoid activities that involve squatting, twisting, or running. Recommend ice application for 15–20 minutes, two to three times daily, along with compression and elevation to reduce swelling.

Prescribe NSAIDs as needed for pain and inflammation, unless contraindicated. Refer the patient to physical therapy for knee strengthening and stability exercises once pain improves. Schedule a follow-up visit in two weeks to review imaging results and reassess symptoms.

Lower Back Pain (Lumbar Strain)

Subjective (S)

The patient reports lower back pain for the past five days. The pain started after lifting heavy boxes at work without proper support. The patient describes the pain as dull and aching, located in the lower back area. Pain is rated 5 out of 10 at rest and increases to 7 out of 10 with bending, lifting, or prolonged sitting. The patient reports morning stiffness that improves slightly with movement during the day.

The patient denies any pain radiating to the legs. There is no numbness, tingling, or weakness in the lower extremities. The patient also denies bowel or bladder changes. Rest and lying flat help reduce the pain, while activity worsens it. The patient has no prior history of back surgery but reports occasional mild back pain in the past that resolved with rest.

Objective (O)

On physical examination, the lumbar spine shows reduced range of motion, especially with forward flexion and extension due to pain. Palpation reveals tenderness over the paraspinal muscles in the lower lumbar region. No spinal deformity, bruising, or swelling is noted. The patient experiences muscle tightness during movement.

Straight leg raise test is negative on both sides, with no reproduction of leg pain. Muscle strength is 5 out of 5 in both lower extremities. Sensation is intact, and reflexes are normal. Gait is slow but stable, with the patient guarding movements to avoid pain.

Assessment (A)

Acute lumbar muscle strain. The patient’s symptoms and physical exam findings are consistent with a soft tissue injury without signs of nerve involvement.

Plan (P)

Recommend relative rest and avoidance of heavy lifting, bending, or twisting movements. Prescribe NSAIDs for pain and inflammation, and a short course of muscle relaxants if muscle spasms persist. Advise the patient to apply heat or ice to the lower back as needed for comfort.

Provide education on proper lifting techniques and posture. Give simple home stretching exercises to improve flexibility. Refer to physical therapy if symptoms do not improve within one week. Schedule follow-up as needed or sooner if symptoms worsen.

Shoulder Pain (Rotator Cuff Tendinitis)

Subjective (S)

The patient reports pain in the left shoulder for the past two months. The pain started gradually without any clear injury. The patient describes the pain as a deep aching pain inside the shoulder, with sharp pain when lifting the arm overhead or reaching behind the back. Pain is rated 5 out of 10 at rest and increases to 7 out of 10 with movement. The patient reports difficulty lifting objects, reaching shelves, and dressing.

The patient also reports that shoulder pain worsens at night, especially when lying on the affected side, which disrupts sleep. Rest helps reduce the pain, while repeated arm use makes it worse. The patient denies numbness, tingling, or pain radiating down the arm. There is no history of shoulder surgery, but the patient reports repetitive overhead activity at work.

Objective (O)

On physical examination, the left shoulder shows reduced active range of motion, especially with abduction and external rotation due to pain. Passive range of motion is slightly better but still painful at the end range. Tenderness is noted over the lateral shoulder and supraspinatus tendon area. No swelling, redness, or bruising is observed.

The painful arc test is positive between 60 and 120 degrees of abduction. Strength testing reveals mild weakness, graded 4 out of 5, during resisted shoulder abduction. Sensation is intact in the upper extremity, and reflexes are normal. Posture shows mild forward shoulder positioning.

Assessment (A)

Left shoulder rotator cuff tendinitis. The patient’s symptoms, physical exam findings, and activity history are consistent with inflammation of the rotator cuff tendons.

Plan (P)

Recommend activity modification and avoidance of overhead lifting and repetitive shoulder movements. Prescribe NSAIDs for pain and inflammation if tolerated. Advise the use of ice packs on the shoulder for 15–20 minutes, two to three times daily.

Refer the patient to physical therapy for shoulder strengthening, range-of-motion exercises, and posture correction. Educate the patient on proper shoulder mechanics and home exercises. Consider imaging, such as ultrasound or MRI, if symptoms do not improve after four to six weeks. Schedule a follow-up visit in one month to reassess pain and function.

Ankle Sprain (Lateral Ligament Injury)

Subjective (S)

The patient reports pain in the left ankle for the past two days. The injury happened while running, when the patient stepped on an uneven surface and twisted the ankle inward. The patient felt immediate pain and had difficulty continuing to walk. The pain is described as sharp at first and now aching, located on the outer side of the ankle. Pain is rated 6 out of 10 at rest and increases to 8 out of 10 when walking or putting weight on the foot.

The patient reports swelling around the ankle and mild bruising that appeared the next day. Walking and standing make the pain worse, while rest and elevation help reduce discomfort. The patient denies numbness or tingling in the foot. There is no history of previous ankle injuries or surgeries.

Objective (O)

On examination, the left ankle shows visible swelling and bruising over the lateral side. Tenderness is noted over the anterior talofibular ligament area on palpation. Range of motion is limited due to pain, especially with inversion and plantar flexion. No open wounds or deformities are observed.

The anterior drawer test of the ankle is positive, indicating ligament laxity. The patient demonstrates an antalgic gait and avoids full weight-bearing on the left foot. Sensation is intact, capillary refill is normal, and distal pulses are present. Muscle strength testing is limited by pain but grossly intact.

Assessment (A)

Left ankle lateral ligament sprain, likely involving the anterior talofibular ligament. Findings are consistent with an acute inversion injury.

Plan (P)

Recommend rest and avoidance of activities that stress the ankle. Apply ice for 15–20 minutes, two to three times daily, along with compression using an elastic bandage and elevation of the ankle to reduce swelling. Provide an ankle brace for support during walking.

Prescribe NSAIDs for pain and inflammation as needed. Advise limited weight-bearing for the next few days, progressing as tolerated. Refer the patient to physical therapy after acute pain decreases for strengthening, balance, and range-of-motion exercises. Schedule a follow-up visit in one week to reassess pain, swelling, and stability.

Common Mistakes in Orthopedic SOAP Notes

Many orthopedic SOAP notes lose quality because important details are missing or unclear. These mistakes can affect patient care, follow-up decisions, and even legal or insurance review. Below are the most common problems clinicians should avoid.

• Writing notes too briefly – Very short notes often miss key information. Orthopedic conditions depend heavily on details like movement limits, pain triggers, and functional impact. A brief note may not fully explain the patient’s condition or progress.
• Not recording pain severity clearly – Pain should always be documented with a number (for example, 0–10). Writing “patient has pain” without a severity level makes it hard to track improvement or worsening over time.
• Unclear or incomplete diagnoses – Using vague terms such as “knee pain” or “shoulder issue” without further explanation weakens the Assessment section. The diagnosis should reflect clinical findings, such as strain, sprain, tendinitis, or suspected tear.
• Vague or weak treatment plans – Plans like “continue treatment” or “follow up later” do not explain what will actually be done. A strong Plan should clearly list medications, therapy, imaging, activity limits, and follow-up timing.
• Mixing opinions into the Objective section – The Objective section should only include what is seen, felt, or measured. Adding opinions or diagnoses here is a common mistake. Clinical judgment belongs in the Assessment section.
• Using unclear language or heavy abbreviations – Overuse of abbreviations or complex medical terms can confuse other providers. This is especially problematic when multiple clinicians are involved in care. Simple, direct language improves clarity and teamwork.
• Not comparing with previous visits – Failing to note whether symptoms are improving, worsening, or unchanged makes progress tracking difficult. Orthopedic care often requires comparison over time.

Avoiding these mistakes helps create clear, accurate, and professional orthopedic SOAP notes that support better patient care and smoother communication between providers.

Tips for Writing Better Orthopedic SOAP Notes

1. Always write clear pain descriptions and use exact numbers when possible. Include pain location, pain type, and pain severity using a scale like 0–10. Record clear measurements such as range of motion, muscle strength, swelling, or gait changes. These details make the note more accurate and useful.
2. When the patient has follow-up visits, compare current findings with previous notes. Clearly state whether the condition is improving, worsening, or staying the same. Focus on function, not only pain. Explain how the problem affects walking, lifting, sitting, standing, sleeping, or work activities.
3. Using structured templates or digital tools can help keep notes consistent and reduce missing information. Well-written orthopedic SOAP notes save time, improve communication between providers, and support better patient care.

Conclusion

Orthopedic SOAP notes are a critical part of musculoskeletal care. They help clinicians document pain, movement, diagnosis, and treatment in a clear and organized way. When written well, SOAP notes improve communication, protect clinicians legally, and support better patient outcomes.

By following the structure explained in this guide and using the examples provided, clinicians and students can confidently write accurate and effective orthopedic SOAP notes every time.