The Quick Guide to Gait SOAP Note Examples for Healthcare Providers

If you've ever struggled to document gait abnormalities in a way that justifies therapy referrals and assistive devices while meeting insurance requirements, this guide is for you.

I've talked to countless physical therapists, neurologists, and primary care physicians who spend excessive time documenting gait assessments, trying to justify physical therapy sessions, assistive device prescriptions, and fall prevention programs.

The reality is that gait documentation has specific requirements that insurance companies scrutinize carefully.

They want to see clear functional deficits, fall risk assessment, specific gait deviations documented, and evidence that interventions are medically necessary to improve safety and mobility.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on patient care.

In this article, I'll show you exactly how to write gait SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for Gait Assessment)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for mobility and gait documentation.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For gait assessment specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of gait deviations and functional mobility limitations
• Appropriate fall risk stratification and safety concerns
• Baseline measurements for tracking treatment progress
• Medical necessity for physical therapy, assistive devices, or home modifications
• Objective findings that support need for continued intervention

SOAP stands for:

• S — Subjective: What the patient reports about walking difficulty, falls, fear of falling, endurance limitations, and functional mobility concerns.
• O — Objective: Your clinical findings including gait observation, balance testing, timed walking tests, assistive device use, and specific gait deviations noted.
• A — Assessment: Your clinical diagnosis with gait pattern classification, fall risk level, functional mobility status, and underlying causes.
• P — Plan: Your treatment plan including physical therapy referrals, assistive device recommendations, home safety modifications, and monitoring parameters.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies interventions to improve patient safety and mobility.

How You Can Approach Gait SOAP Notes

There's no single correct method for writing gait SOAP notes, but some approaches work better than others depending on your practice setting.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after observing and assessing the patient's gait. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and notes can become inconsistent, especially when describing specific gait deviations or quantifying balance deficits.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for in gait and mobility documentation.

How to Make Gait SOAP Notes Faster

One of the biggest complaints I hear from providers assessing gait is how documentation eats into their already limited time.

You've just finished evaluating multiple patients with complex mobility issues, each requiring detailed observation and testing, and instead of moving on to treatment or other responsibilities, you're stuck typing lengthy notes for insurance.

The pressure is real: make them too brief and you risk denials for PT authorization or assistive device coverage; make them too detailed and you've just added hours to your documentation time.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after assessment, add rough notes about specific gait deviations, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"Antalgic gait favoring left leg, decreased step length, TUG test 18 seconds, uses single-point cane, moderate fall risk, needs PT for strengthening and balance."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Post-Stroke Gait Abnormality, PT Evaluation

Patient: 67-year-old male
Chief Complaint: Difficulty walking after recent stroke
Visit: Initial physical therapy evaluation

S – Subjective:

Patient reports difficulty walking since CVA 6 weeks ago affecting right side. Describes right leg as "heavy" and "not cooperating." Requires verbal cueing from family to lift foot when walking. Has fallen twice at home in past 2 weeks, both times when turning. Reports fear of falling limits his willingness to walk independently. Prior to stroke, walked independently without assistive device for all activities. Currently using standard cane provided by hospital but unsure of proper technique. Fatigues quickly, can walk only 50-100 feet before needing rest. Unable to climb stairs safely. Needs assistance with bathing due to balance concerns.

O – Objective:

Ambulation Status: Ambulates with single-point cane in left hand, contact guard assistance required for safety.
Gait Observation: Right hemiparetic gait pattern noted. Decreased right hip flexion during swing phase with compensatory circumduction. Foot drop present on right with toe drag during swing. Decreased right step length (approximately 8 inches vs 14 inches on left). Wide base of support. Reduced right arm swing. Decreased stance time on right lower extremity.
Balance: Static standing balance fair with assistive device, poor without device. Unable to perform single-leg stance on either side. Romberg test positive with significant sway.
Timed Up and Go (TUG): 22 seconds (high fall risk, normal less than 12 seconds).
Berg Balance Scale: 38/56 (moderate fall risk).
Strength: Right lower extremity 3+/5 hip flexors, 3/5 ankle dorsiflexors, 4/5 knee extensors. Left lower extremity 5/5 throughout.
ROM: Right ankle limited dorsiflexion (passive 0 degrees, active -5 degrees), all other joints within functional limits.

A – Assessment:

67-year-old male with right hemiparetic gait pattern secondary to recent left hemisphere CVA. Significant gait deviations including foot drop, circumduction, and asymmetric step length. High fall risk evidenced by TUG test greater than 20 seconds, Berg score less than 40, and history of recent falls. Moderate assistance required for safe ambulation. Functional mobility severely limited compared to prior level. Patient demonstrates good rehabilitation potential given recent stroke timeline and motivation.

P – Plan:

Initiated physical therapy 3x/week for 8 weeks focusing on: gait training with emphasis on right lower extremity strengthening and motor control, balance activities progressing from static to dynamic tasks, fall prevention strategies and education. Recommend evaluation for ankle-foot orthosis (AFO) to address foot drop and improve safety. Recommend upgrade to quad cane or rolling walker for improved stability during gait training progression. Home exercise program provided including ankle pumps, hip flexion exercises, and standing balance activities. Family education on contact guard assistance and home safety modifications. Recommend removal of throw rugs and installation of grab bars. Reassess gait pattern and fall risk in 4 weeks. Goal: independent ambulation with appropriate assistive device for household distances within 8 weeks.

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Example 2: Antalgic Gait Due to Hip Osteoarthritis

Patient: 72-year-old female
Chief Complaint: Limping and difficulty walking due to hip pain
Visit: Primary care follow-up for chronic hip pain

S – Subjective:

Patient reports progressively worsening right hip pain over past 6 months with associated limping. Pain rated 6/10 with walking, 3/10 at rest. Describes pain as deep ache in groin and lateral hip, worse after walking more than one block. Notices she's walking slower and avoids walking longer distances. No history of falls but reports feeling unsteady at times due to favoring right leg. Morning stiffness lasts approximately 30 minutes. Takes acetaminophen 650mg twice daily with moderate relief. Previously very active, now limiting walks with spouse due to pain and fatigue. Denies nighttime pain unless she's been particularly active during day.

O – Objective:

Ambulation: Independent without assistive device but demonstrates antalgic gait pattern.
Gait Observation: Shortened stance phase on right lower extremity (painful side). Decreased right step length. Lateral trunk lean toward right during right stance phase to decrease joint loading. Reduced hip extension on right during terminal stance. Normal cadence but slower walking speed than age-matched peers.
Walking Speed: 10-Meter Walk Test at 0.8 m/s (slow for age, normal greater than 1.0 m/s).
Hip ROM: Right hip flexion 95° (limited), internal rotation 10° (limited), external rotation 20° (limited). Left hip WNL.
Strength: Right hip abductors 4-/5, otherwise 5/5 bilateral lower extremities.
Palpation: Tenderness over right greater trochanter and anterior hip joint line.
X-ray Right Hip: Moderate to severe osteoarthritis with joint space narrowing, osteophyte formation, and subchondral sclerosis.

A – Assessment:

Antalgic gait pattern secondary to right hip osteoarthritis, moderate to severe by radiographic findings. Gait deviation with shortened stance phase and trunk lean as compensatory strategies to reduce pain. Functional mobility declining with reduced walking speed and endurance. Fall risk currently low but may increase with disease progression and continued compensation patterns. Conservative management appropriate at this time prior to surgical consideration.

P – Plan:

Referred to physical therapy for 6-week trial focusing on: hip strengthening (particularly abductors), gait training to normalize pattern, pain management modalities, and aquatic therapy if available. Recommended single-point cane for right hand use (opposite side of painful hip) to reduce joint loading during ambulation and improve gait symmetry. Instructed on proper cane height and usage. Increased NSAIDs to naproxen 500mg BID with food for 4 weeks. Discussed weight management benefits for hip OA (patient BMI 29). Provided information on hip replacement surgery as future option if conservative measures fail. Ordered DEXA scan to assess bone density prior to potential surgery. Follow-up in 6 weeks to reassess pain, function, and gait pattern. If no improvement, will refer to orthopedic surgery for joint replacement consultation. Patient educated on activity modification: avoid prolonged standing, use assistive device as recommended, continue low-impact exercise.

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Example 3: Parkinsonian Gait, Neurology Follow-Up

Patient: 75-year-old male
Chief Complaint: Walking problems and freezing episodes
Visit: Neurology follow-up for Parkinson's disease

S – Subjective:

Patient with known Parkinson's disease for 5 years reports increasing difficulty with walking over past 3 months. Describes episodes of "freezing" where feet feel "stuck to the floor," particularly when initiating gait or turning. Freezing episodes occur 5-6 times daily, lasting 10-30 seconds. Wife reports shuffling gait has worsened. Patient fell once last month when frozen episode occurred near stairs. Denies injury from fall. Reports difficulty with turning in bed and getting out of chairs. Currently taking carbidopa-levodopa 25/100mg three times daily, last dose adjustment 8 months ago. Symptoms worst in morning before first medication dose and late afternoon.

O – Objective:

Ambulation: Independent but demonstrates multiple parkinsonian gait features.
Gait Observation: Shuffling gait with reduced step length bilaterally (approximately 8-10 inches). Decreased arm swing bilaterally, more pronounced on left. Stooped, forward-flexed posture. En bloc turning (turns body as single unit rather than sequential rotation). Narrow base of support. Reduced gait speed. Festinating gait noted when attempting to walk faster. No freezing observed during office visit.
Pull Test: Required two steps to recover balance (abnormal, indicates postural instability).
Gait Speed: 10-Meter Walk Test at 0.6 m/s (significantly impaired).
Timed Up and Go: 25 seconds (high fall risk).
UPDRS Motor Score: 38 (moderate motor impairment, increased from 28 at last visit 6 months ago).
Cognition: Montreal Cognitive Assessment (MoCA) 24/30 (mild impairment).

A – Assessment:

Progressive parkinsonian gait with festination, reduced step length, and freezing of gait (FOG) episodes. Postural instability developing as evidenced by abnormal pull test and recent fall. Motor symptom progression despite current medication regimen suggests need for adjustment. High fall risk given FOG episodes, postural instability, and TUG greater than 20 seconds. Mild cognitive changes may impact safety awareness and compensatory strategies.

P – Plan:

Medication adjustment: Increase carbidopa-levodopa to 25/100mg four times daily to provide better symptom coverage throughout day, particularly targeting morning and late afternoon symptom worsening. Added rasagiline 1mg daily as adjunct therapy. Referred to physical therapy specializing in Parkinson's disease for: gait training with cueing strategies (visual lines, auditory rhythm), freezing of gait management techniques, balance and postural stability exercises, fall prevention education. Recommended evaluation for rolling walker with seat to provide stability and resting option during freezing episodes. Patient and wife educated on FOG strategies: stepping over imaginary line, marching in place, shifting weight side to side. Home safety evaluation recommended through PT for environmental modifications. Discussed fall risk and importance of supervision during high-risk activities. Referred to occupational therapy for activities of daily living assessment and adaptive equipment. Follow-up in 6 weeks to assess medication response and therapy progress. Consider neurology PT/OT home program if insurance approves. Patient and family verbalized understanding of fall risk and strategies to implement.

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Key Components Insurance Companies Look For in Gait SOAP Notes

When reviewing your gait documentation, insurance companies specifically want to see:

1. Specific Gait Deviations

Document observable gait abnormalities: antalgic, hemiplegic, Trendelenburg, steppage, ataxic, parkinsonian, etc. Vague terms like "abnormal gait" won't justify treatment.

2. Quantitative Measurements

Include objective measures: TUG test, 10-Meter Walk Test, Berg Balance Scale, gait speed. These provide baseline and track progress.

3. Fall Risk Assessment

Document fall history, fall risk scores, and specific safety concerns. This justifies assistive devices and intensive therapy.

4. Functional Impact

Clearly describe how gait abnormality affects daily activities: walking distances, stair negotiation, community ambulation, independence level.

5. Assistive Device Justification

Document medical necessity for canes, walkers, or orthotics based on specific deficits and safety needs.

6. Therapy Goals and Timeline

Specific, measurable goals with realistic timeframes show medical necessity for continued treatment sessions.

Common Mistakes to Avoid

Vague Gait Descriptions: Instead of "walks with difficulty," document specific deviations like "antalgic gait with shortened right stance phase and lateral trunk lean."

Missing Quantitative Data: Always include at least one objective measure (TUG, walking speed, balance score) to establish baseline and track progress.

No Fall Risk Documentation: Insurance heavily weighs fall risk when approving PT or assistive devices. Document fall history and risk assessment.

Incomplete Functional Status: Document what patient can and cannot do: "ambulates 50 feet before requiring rest" vs "limited ambulation."

Missing Assistive Device Assessment: Document if patient uses device, uses it correctly, and whether current device is appropriate for their needs.

No Treatment Progression: Show how gait and function change over time. Without documented progress, insurance may deny continued therapy.

Final Thoughts

Gait SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent treating patients and improving their mobility than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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