Why SOAP Notes Still Matter in 2025
SOAP notes have been the standard of clinical documentation since the 1960s. In 2025 they remain the most widely accepted format for physiotherapists, occupational therapists, psychologists and other allied-health professionals.
The catch? Documentation demands are exploding. Nearly 75 % of clinicians say documentation impedes patient care[1]. Ambient AI transcription is relieving that burden, trimming after-hours note work by up to 30 %[2], and the global healthcare-NLP market is projected to soar from $3.51 billion in 2024 to $12.38 billion by 2033[3].
Meanwhile, 65 % of companies now report regular generative-AI use[4], signalling that automated documentation is moving from “nice-to-have” to clinical standard.
The SOAP Framework
1 — Subjective (S)
Purpose Capture the patient’s own words, symptoms and goals. This is where context lives.
- Use brief quotations to preserve nuance (“My knee feels like it will give way”).
- Include caregiver observations for paediatric or geriatric cases.
- Document pain scales, adherence issues, lifestyle factors.
2 — Objective (O)
Purpose Record measurable facts you observed or tested.
- Vitals, range-of-motion (ROM), manual-muscle-testing, lab results.
- Standardised outcome measures (e.g., DASH, Berg, PHQ-9).
- Environmental or assistive-device details that affect performance.
3 — Assessment (A)
Purpose Provide your professional analysis. Tie every inference back to evidence in S + O.
- Synthesise patterns: “Pain onset correlates with knee valgus and quad weakness.”
- Update ICD-10 codes and goal status in plain language.
- Flag barriers (transport, mental-health, funding) that may derail progress.
4 — Plan (P)
Purpose Lay out next steps that anyone on the care team can follow.
- Dose-specific interventions (“Theraband quad sets 3 × 15, daily”).
- Education, referrals, assistive-tech trials.
- Target dates and criteria for discharge or progression.
Regulatory & Audit Must-Knows for 2025
Compliance bodies from CMS in the United States to the Australian Health Practitioner Regulation Agency (AHPRA) still review health notes against SOAP-aligned quality indicators: clarity, legibility, evidence-based assessment, and continuity. Audit failures most often stem from:
- Copy-paste drift — old goals left unedited.
- Mismatched objective data — ROM recorded but never referenced in Assessment.
- Unbillable abbreviations — use agency-approved lists only.
Tip: embed standardised outcome tools (e.g., PSFS, FIM) into SOAP templates so scores auto-populate the Objective field, ensuring every Assessment statement is traceable.
SOAP Note Examples
Physiotherapy Progress Note
| Section | Example Entry |
|---|---|
| S | “Left knee pain 6/10 after 20 min of walking; wants to resume jogging before City-to-Surf.” |
| O | ROM 0-105° flexion (–5° vs contralateral); MMT quads 4/5; swelling +1 cm. Single-leg hop 15 cm (↓40 %). |
| A | Pain likely driven by quad weakness and residual effusion. Running tolerance improving; on track for 5 km jog + pain ≤3/10 by week 6. |
| P | Progress Theraband quad sets to 2 kg ankle weight 3 × 15; add step-downs 3 × 10; ice 10 min post-exercise; review in 1 week. |
Psychology Initial Session
| Section | Example Entry |
|---|---|
| S | Client reports persistent worry about work performance; sleep = 4–5 hrs/night; denies suicidal ideation. |
| O | GAD-7 = 14 (moderate); affect congruent, speech normal rate; no psychomotor agitation. |
| A | Presentation consistent with Generalised Anxiety Disorder; functional impairment in concentration and sleep. |
| P | Begin CBT weekly; introduce sleep-hygiene diary; consider referral for GP medication review if GAD-7 > 15 at week 4. |
Common Pitfalls & Quick Fixes
- Vague goals → Use SMART language (“Walk 500 m with single-point cane in < 7 min by 8 Aug 2025”).
- Assessment mirrors Subjective → Add clinical interpretation, not repetition.
- Overly long paragraphs → Break into bullet points; auditors skim.
Tips for Allied-Health Professionals
Integrate Outcome Measures
Add drop-downs for standardised tools in your EHR template. AmeoHealth can auto-detect “Berg Score 46” in dialogue and insert it under Objective.
Leverage Smart Snippets
Create text-expander codes for common interventions (e.g., “hmep” → “Home exercise program emailed and demonstrated”). This maintains consistency and speeds signing.
Audit-Proof Your Note
Before finalising, ask yourself: “If I were absent, could a colleague treat this patient tomorrow using only this note?” If no, flesh out your Plan.
Time-and-Money Math for 2025
Documentation isn’t merely an annoyance – it’s a cost centre. A mid-sized physio clinic producing 60 notes/day at 7 min each spends 35 clinic-hours/week on typing. With ambient AI trimming 30 % of that across the team, the clinic regains ten billable treatment sessions weekly. Multiply by average Australian consult fees and the ROI becomes obvious.
Industry sentiment is shifting, too. 50.9 % of nurses reported being satisfied with their EHR in 2023 – up from 38.4 % in 2019[5]. Better tooling is turning documentation from burnout trigger into competitive advantage.
Takeaway
The future of documentation isn’t less documentation—it’s smarter documentation. Master the SOAP framework, automate the grunt work with AmeoHealth, and spend your reclaimed time where it matters: delivering top-tier patient care.
References
- American Medical Informatics Association — “AMIA Survey Underscores Impact of Excessive Documentation Burden” — Link (Published: June 3, 2024)
- The Washington Post — “This technology is becoming beloved by doctors and patients alike” — Link (Published: March 25, 2025)
- Verified Market Reports — “Healthcare Natural Language Processing (NLP) Market Size & Forecast 2033” — Link (Published: February 2025)
- McKinsey & Company — “The State of AI in Early 2024: Gen AI Adoption Spikes and Starts to Generate Value” — Link (Published: May 30, 2024)
- Oncology Nursing Society — “Nurses Identify EHR Improvement Opportunities That Could Reduce a Source of Burnout” — Link (Published: October 30, 2024)