How do you write a physiotherapy case sheet?

A case sheet has two readers: you in six weeks, and whoever covers for you when you are away. Both of them need the same thing — measurements they can compare against, and reasoning they can follow. A paragraph of prose serves neither.

The four-part structure below is the physiotherapy application of the SOAP format used across clinical practice. It is not a bureaucratic requirement; it is the shortest form that keeps a record comparable across sessions.

1. Subjective — what the patient reports

The patient's own account, in their terms. Record what they say, not your interpretation of it — the interpretation belongs in the assessment.

• Presenting complaint and how long it has been going on.
• Mechanism of onset — what they were doing when it started, or whether it came on gradually.
• Pain: location, character, and a numeric rating. Always record the scale you used, and use the same one every time.
• Aggravating and easing factors — this is often where the treatment plan actually comes from.
• Twenty-four hour pattern — morning stiffness, night pain, effect of activity.
• Functional limitation in the patient's own words. "I cannot get up the stairs at work" is more useful than "reduced mobility", because it is measurable and it is what success will look like to them.
• Relevant history: previous episodes, surgery, imaging, medication, other conditions.
• The patient's goal. Write it down. It is the thing you are actually treating.

2. Objective — what you measure

This is the section that makes a case sheet worth keeping. Every entry should be a number, a side-to-side comparison, or a clearly named test with a stated result.

• Observation: posture, swelling, gait, guarding, wasting.
• Range of motion, in degrees, stating active or passive and how it was measured. "Knee flexion 0–96° active, goniometer" is a record. "ROM reduced" is not.
• Strength, using a named scale — for example the Oxford scale — with the grade and the side compared.
• Special tests, named, with the result and which side.
• Palpation findings and neurological screening where relevant.
• Functional measures and outcome scores. If you use a standardised score, use the same one at every reassessment.

3. Assessment — what you conclude

Your clinical reasoning, stated plainly. This is the section most often skipped and the one that matters most when someone else picks up the case.

• Your working hypothesis, and what the findings support it.
• Contributing factors — occupational, postural, training load, previous injury.
• Irritability and stage of healing, because they determine dosage.
• Any red flags considered and excluded. Write down that you considered them.
• Prognosis and the expected timeframe.

4. Plan — what you will do

• Treatment delivered in this session, with dosage.
• Home exercise programme, with sets, repetitions and frequency.
• Advice and education given.
• Planned frequency and expected number of sessions.
• Reassessment markers — what you will measure next time to decide whether this is working, and the threshold at which you would change approach.

A worked example

What to avoid

• Abbreviations only you understand. If a colleague covering your list cannot read it, it is not a record.
• Descriptions where numbers belong. "Improving" is not a measurement.
• Copying the previous session forward. A duplicated note tells the next reader nothing and, if a record is ever examined, is worse than no note at all.
• Writing it up later. Notes written from memory at the end of the day lose exactly the detail that made them worth taking.

Structure beats effort

The reason structured case sheets work is not that they make you write more. They make you write less, because the structure tells you what is worth recording and what is not. That is why the case sheets in Kinetiq follow this shape rather than offering a blank box — a blank box is a decision you have to make forty times a day.