The therapist's professional opinion on the patient's progress and how they are responding to the treatment plan .
Record the patient's self-reported pain levels, improvements, or struggles since the last session.
Measurable data, such as range of motion (ROM) , strength test results, and specific exercises completed.
Medical professionals use the SOAP Note format to document patient progress.
This write-up is often required by insurance companies like Texas Health and Human Services to justify why a patient needs continued rehabilitation services . Rehabilitation after traumatic injury - NCBI Bookshelf
Steps for the next session, including SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound). 2. Letter of Medical Necessity (LMN)
Depending on your goal—whether you are a healthcare professional documenting a session, a patient sharing a review, or a student writing about the field—physical rehabilitation requires different styles of write-ups.
