Sleep Ergonomics SOAP Note Example physcal therapy

Low back pain is a common condition that physical therapists encounter frequently in their practice. Proper documentation through SOAP notes is crucial for effective patient care and treatment planning.

This comprehensive guide on Back Pain SOAP Notes will explore the intricacies of writing SOAP notes for low back pain in physical therapy. It will provide examples and insights to help therapists improve their documentation skills.

Sleep Ergonomics SOAP note example

SUBJECTIVE

Chief Complaint (CC): “Chronic neck pain and stiffness in the morning for the past 3 months”

History of Present Illness (HPI):

• Location: Posterior neck region bilaterally with predominance on right side, radiating to right shoulder
• Onset: Gradual onset approximately 3 months ago, coinciding with new job position
• Character: Deep, achy pain with associated stiffness
• Associated Symptoms: Bilateral arm numbness during sleep, decreased sleep quality
• Timing: Worst in morning (6/10), improves throughout day (3/10)
• Exacerbating Factors: Prolonged sleep position, computer work, end of workday
• Severity: 6/10 at worst (morning), 3/10 at best (evening)

Past Medical History:

• Mild anxiety (diagnosed 2020)
• Right shoulder impingement (2019, resolved with PT)

Surgical History:

• Denies past surgeries

Family History:

• Father: HTN, Type 2 Diabetes
• Mother: Fibromyalgia
• Siblings: None reported

Social History:

• Occupation: Software Developer (remote work, 50-60 hours/week)
• Living Situation: Lives alone in one-bedroom apartment
• Sleep Environment: 5-year-old medium-firm mattress, uses two pillows
• Sleep Schedule: 12 AM – 6 AM (averaging 5-6 hours/night)
• Exercise: Sedentary lifestyle, occasional weekend walks
• Screen Time: 12+ hours daily (work + leisure)
• Stress Level: Moderate to high due to work demands
• Tobacco: Denies
• Alcohol: 1-2 drinks/week
• Recreational Drugs: Denies

Current Medications:

• Escitalopram 10mg PO daily
• Ibuprofen 400mg PO PRN pain

Allergies:

• NKDA (No Known Drug Allergies)
• No known environmental allergies

Review of Systems:
Constitutional: Reports fatigue, disrupted sleep patterns, denies fever/chills
HEENT: Denies headaches, visual changes, jaw pain
Cardiovascular: Denies chest pain, palpitations, edema
Respiratory: Denies SOB, cough
Gastrointestinal: Denies changes in appetite, nausea
Musculoskeletal: Reports morning neck stiffness, upper back tension
Neurological: Reports intermittent numbness in both arms during sleep
Psychological: Reports mild anxiety about sleep quality
Skin: Denies rashes, lesions
All other systems reviewed and negative

OBJECTIVE

Vital Signs:

• Blood Pressure: 122/78 mmHg
• Heart Rate: 72 bpm, regular
• Respiratory Rate: 16 breaths/min
• Temperature: 98.6°F
• Height: 5’10” (177.8 cm)
• Weight: 175 lbs (79.4 kg)
• BMI: 25.1 kg/m²

General Appearance:

• 35-year-old male in no acute distress
• Well-groomed, appropriate affect
• Forward head posture noted
• Rounded shoulders observed
• Increased thoracic kyphosis

Cervical Range of Motion (Measured with Goniometer):
Flexion: 45° (Normal 50°) – limited by stiffness
Extension: 40° (Normal 60°) – limited by pain
Right Rotation: 60° (Normal 80°) – limited by pain
Left Rotation: 70° (Normal 80°)
Right Lateral Flexion: 35° (Normal 45°) – limited by stiffness
Left Lateral Flexion: 40° (Normal 45°)

Palpation:

• Increased muscle tone in upper trapezius bilaterally (R>L)
• Tender to palpation over cervical paraspinals (R>L)
• Multiple trigger points in levator scapulae (R>L)
• Suboccipital muscle tension noted bilaterally
• Tissue temperature normal and symmetric

Strength Testing (Manual Muscle Testing):
Upper Extremity:

• Shoulder Flexion: 5/5 bilaterally
• Shoulder Abduction: 5/5 bilaterally
• Elbow Flexion/Extension: 5/5 bilaterally
• Wrist Flexion/Extension: 5/5 bilaterally

Cervical Spine:

• Flexors: 4/5
• Extensors: 4+/5
• Deep Neck Flexors: Poor endurance on cranio-cervical flexion test
• Scapular Stabilizers: 4-/5

Special Tests:

• Spurling’s Test: Negative bilaterally
• Upper Limb Tension Test: Negative bilaterally
• Cervical Distraction Test: Negative
• Cranio-cervical Flexion Test: 22 mmHg (indicating poor deep neck flexor endurance)
• Upper Trapezius Length Test: Shortened bilaterally
• Lateral Scapular Slide Test: Positive for scapular dyskinesis

Neurological Screen:

• Deep Tendon Reflexes: 2+ and symmetric in upper extremities
• Sensation: Intact to light touch in all dermatomes C5-T1
• Motor: No focal deficits noted
• Coordination: Normal finger-to-nose testing

Sleep Ergonomics Assessment:

• Current pillow: Two standard pillows (excessive height)
• Mattress: Medium-firm, 5 years old, visible sagging in middle
• Preferred sleep position: Side-lying with neck flexed
• Workspace ergonomics: Poor monitor height, non-adjustable chair

ASSESSMENT

Primary Diagnosis:

• Cervical myofascial pain syndrome (M54.2) related to poor sleep ergonomics and postural strain

Contributing Factors:

1. Poor sleep positioning with excessive cervical flexion
2. Inadequate mattress support due to age and wear
3. Improper pillow height causing cervical misalignment
4. Prolonged static postures during workday
5. Decreased cervical and scapular muscle strength
6. Poor sleep hygiene affecting quality and duration of sleep
7. Postural dysfunction (forward head, rounded shoulders)

Functional Limitations:

1. Unable to maintain sleep > 6 hours due to pain/discomfort
2. Decreased cervical ROM limiting checking blind spots while driving
3. Difficulty maintaining proper posture during workday
4. Limited ability to perform overhead activities due to neck pain

PLAN

Treatment Frequency:
2x/week for 4 weeks, then reassess

Interventions:

1. Manual Therapy:

• Soft tissue mobilization to cervical paraspinals
• Trigger point release to upper trapezius and levator scapulae
• Joint mobilization to cervical and thoracic spine
• Myofascial release to suboccipital region

1. Therapeutic Exercise:

• Deep neck flexor training protocol
• Scapular stabilization exercises
• Postural correction exercises
• Upper trapezius and levator scapulae stretching

1. Sleep Ergonomics Education:

• Proper pillow selection and positioning
• Optimal sleep positions demonstration
• Mattress education and recommendations
• Sleep hygiene guidelines
• Pre-sleep stretching routine instruction

1. Home Exercise Program (HEP):

• Cervical ROM exercises (10 reps, 3x/day)
• Deep neck flexor strengthening (10 reps, 10-second holds)
• Upper trapezius stretching (3×30 seconds, 3x/day)
• Thoracic extension exercises (10 reps, 2x/day)
• Scapular retraction exercises (15 reps, 2x/day)

1. Equipment Recommendations:

• Cervical contour pillow (single)
• Ergonomic workstation assessment
• Consider mattress replacement if no improvement in 4 weeks

Short-term Goals (2 weeks):

1. Reduce morning pain to 4/10
2. Increase cervical ROM by 25%
3. Improve sleep duration to 6-7 hours without interruption
4. Independence with HEP
5. Demonstrate proper sleep positioning

Long-term Goals (4-6 weeks):

1. Morning pain reduced to ≤2/10
2. Full cervical ROM
3. Consistent 7-8 hours of uninterrupted sleep
4. Normal deep neck flexor endurance
5. Return to all activities without pain
6. Independent management of symptoms

Patient Education:

• Explained findings and treatment plan
• Reviewed proper sleep positioning
• Demonstrated HEP exercises
• Discussed workplace ergonomic modifications
• Provided sleep hygiene handout

Patient educated on all aspects of the plan and demonstrates understanding. Will reassess in 2 weeks for progression.

Lower Back Pain SOAP Note Example

SUBJECTIVE

Chief Complaint (CC): “Pt complains of low back pain for 2 days following an injury.”

History of Present Illness (HPI):

• Location: Lower mid back, denies radiation
• Onset: 2 days ago while lifting bike and climbing stairs
• Character: Sharp, intense pain
• Associated Symptoms: No numbness, tingling, or weakness
• Timing: Constant
• Exacerbating Factors: Moving and bending back
• Severity: 7/10 pain scale

Past Medical History:

• Denies past medical conditions
• Denies injuries
• Denies hospitalizations
• Denies transfusions
• Denies psychiatric diseases
• Denies childhood diseases

Surgical History:

• Denies past surgeries

Family History:
Maternal Side:

• Grandmother: Deceased at age 72 (unknown reason), HTN
• Grandfather: Alive age 75, Parkinson’s Disease

Paternal Side:

• Grandmother: Alive age 75, TIA, Hyperlipidemia
• Grandfather: Alive age 76, No known medical problems

Parents:

• Mother: Alive age 50, HTN, Hyperlipidemia
• Father: Deceased at age 51 due to CVA, History of HTN

Social History:

• Marital Status: Single
• Living Situation: Lives with roommates
• Occupation: Receptionist at doctor’s office
• Insurance: United Healthy Community Plan, low-income
• Tobacco/Vaping: Denies
• Alcohol: Holiday use only, 2 glasses of wine
• Drug Use: Denies
• Activities: Enjoys hunting with friends
• Safety: Uses helmet when riding bike, denies driving
• Nutrition: No dietary restrictions, maintains healthy weight
• Language: English
• Assistive Devices: Denies

Immunizations:

• Covid vaccine series complete:
• 1st dose: 3/20/2021
• 2nd dose: 4/17/2021
• Booster: 12/30/2021
• Tetanus booster: April 2022
• Flu shot: October 2023
• All other immunizations up to date per CDC guidelines

Allergies:

• NKDA
• No known food allergies

Current Medications:

• Tylenol (OTC) 325mg x2 tablets PO PRN for pain

Review of Systems:

• General: A&Ox3, denies nausea, vomiting, chills, night sweats, weakness, weight/appetite changes
• Skin: Denies rash, itching, lesions, pigment changes, excessive sweating, hair/nail changes
• Head: Denies headache, dizziness, syncope, injury
• Neck: Denies swollen glands, pain, stiffness, ROM changes
• Respiratory: Denies pain, SOB, wheezing, cough, sputum
• Cardiac: Denies chest pain, palpitations, edema, murmur
• Peripheral Vascular: Denies cramps, varicose veins, clot history
• Musculoskeletal: Reports low back pain with bending/position changes, slow movement needed
• Neurological: Denies numbness, tingling, weakness, tremor, sensory loss, speech/memory changes
• Psychiatric: Denies SI/HI
  All other systems reviewed and negative

OBJECTIVE

Vital Signs:

• BP: 116/64 mmHg
• HR: 68 bpm
• RR: 18 breaths/min
• O2 Sat: 97% on room air
• Temp: 97°F
• Height: 5’4″
• Weight: 117 lbs
• BMI: 20.0

General Appearance:

• Well-developed
• Calm and cooperative
• Clear speech

Physical Examination:
HEENT:

• Head: Symmetric, normocephalic, no injury
• Neck: Thyroid palpable, normal size
• No lymphadenopathy
• Carotids 2+ bilaterally, no bruits
• Normal ROM

Skin:

• Pink, warm, dry, intact
• Uniform throughout
• No pallor, cyanosis, jaundice, or lesions
• Capillary refill <3 seconds
• No abnormal hair or nails

Respiratory:

• Lungs clear to auscultation bilaterally
• No wheezing, rales, or rhonchi

Cardiovascular:

• S1, S2 present
• No murmur
• Regular rate and rhythm

Peripheral Vascular:

• No edema of bilateral lower extremities

Gastrointestinal:

• Abdomen soft, non-tender
• Positive bowel sounds in all four quadrants
• No hepatomegaly or spleen enlargement
• No CVA tenderness

Musculoskeletal:

• Gait: Walking slowly due to lower midback pain
• Strength: 5/5 bilateral upper and lower extremities
• ROM: Full in all extremities

Neurological:

• Alert and oriented x3
• No focal deficits

Testing/Lab Results:

• None performed

ASSESSMENT

Primary Diagnosis:

• Acute lumbosacral strain – S39.012A

Differential Diagnoses:

1. Muscle spasm of back – M62.830
2. Wedge compression fracture of unspecified lumbar vertebra – S33.000
3. Herniation lumbar intervertebral disc – M51.87

PLAN

Diagnostic Studies:

1. Spine X-ray to rule out fracture
2. MRI lumbar spine without contrast

• To evaluate for soft tissue, ligament problems, spinal problems, nerve issues, or inflammation

Medications:

• Ibuprofen (Nurofen) 600 mg PO q6h PRN for 4 days

Treatment Plan:

1. Cold compress for inflammation and pain relief
2. Physical exercises as tolerated
3. Follow up in 1 week for:

• Review test results
• Assess patient progress
• Evaluate response to treatment

1. Return sooner if symptoms worsen

Patient Education:

• Instructed to contact healthcare provider if symptoms worsen
• Patient verbalized understanding of plan and agrees with treatment

References:

1. Al Qaraghli, M. I., & De Jesus, O. (2020). Lumbar Disc Herniation. PubMed; StatPearls Publishing.
2. Seller, R. H., & Symons, A. B. (2017). Differential diagnosis of common complaints. Elsevier.
3. Urits, I., et al. (2019). Low back pain, a comprehensive review: Pathophysiology, diagnosis, and treatment. Current Pain and Headache Reports, 23(3).

A SOAP note for low back pain is a structured method of documentation used by physical therapists to record patient information, assessment findings, and treatment plans. SOAP stands for Subjective, Objective, Assessment, and Plan, which are the four main components of this documentation format.

To improve the quality of SOAP notes, avoid these common pitfalls:

• Using vague or subjective language instead of specific, measurable terms
• Omitting important details about the patient’s condition or treatment
• Failing to update the assessment and plan based on new findings
• Overusing abbreviations that may not be universally understood

Related Article

SOAP Note Example Templates

FAQs

What is an example of a SOAP note for pain?

A SOAP note for pain typically includes the patient’s description of pain (location, intensity, quality), objective measurements (e.g., range of motion, strength), the therapist’s assessment of the pain’s cause, and a plan for pain management and treatment.

How to write soap notes for physical therapy?

To write SOAP notes for physical therapy, follow the SOAP format: Subjective (patient’s reports), Objective (measurable findings), Assessment (therapist’s interpretation), and Plan (treatment strategy). Be concise, specific, and focus on relevant information for the patient’s condition and treatment.

What is a comprehensive SOAP note?

A comprehensive SOAP note includes detailed information in all four sections (Subjective, Objective, Assessment, Plan), providing a thorough picture of the patient’s condition, examination findings, clinical reasoning, and treatment approach. It should be detailed enough to guide ongoing care and communicate effectively with other healthcare providers.

What is the brief pain inventory for low back pain?

The Brief Pain Inventory (BPI) for low back pain is a standardized assessment tool that measures pain intensity and its impact on daily functions. It typically includes questions about pain severity, location, and how it affects activities such as work, sleep, and mood. This inventory helps track changes in pain over time and assess the effectiveness of interventions.