The 2026 Guide to Orthopedic SOAP Note

Orthopedic documentation carries higher stakes than almost any other specialty.

A primary care note that's "good enough" might pass without issue, but in orthopedics, inadequate documentation can mean:

• Denied prior authorizations for $40,000 surgeries
• Insurance refusing to cover advanced imaging that changes your surgical plan
• Physical therapy claims rejected for lack of medical necessity
• Post-operative complications blamed on inadequate pre-surgical assessment
• Malpractice attorneys questioning whether you properly evaluated alternative treatments

I've watched orthopedic surgeons and their staff spend 15-20 hours per week fighting insurance denials that could have been prevented with better initial documentation.

The frustration is real: you performed a thorough examination, made the right clinical decisions, and the patient is improving—but your notes don't capture what actually happened in a way insurance companies understand.

That's the problem I built SOAP Notes Doctor to solve.

This guide shows you exactly what orthopedic SOAP notes need to satisfy insurance requirements while actually supporting your clinical decision-making.

Why Orthopedic Documentation Is Under Intense Scrutiny

Insurance companies lose money on orthopedic procedures.

A knee arthroscopy costs them $15,000. A total joint replacement: $30,000-50,000. Spine surgery: often exceeding $100,000.

So they audit orthopedic notes more aggressively than almost any other specialty, looking for reasons to deny or delay expensive procedures.

Here's what they're specifically searching for in your documentation:

Conservative treatment failures: They want proof you tried cheaper options first—physical therapy, injections, medications—before proceeding to surgery.

Functional limitations: Vague statements like "knee pain" don't justify surgery. They need documented evidence of disability: "unable to climb stairs," "cannot complete work duties," "uses assistive device."

Objective findings correlating with symptoms: If your patient reports 10/10 pain but walks normally without limping and has full range of motion, the note creates doubt about severity.

Imaging findings that match clinical presentation: Your notes need to tie together symptoms, exam findings, and imaging abnormalities into a coherent clinical picture.

Surgical necessity over convenience: Insurance denies procedures that seem elective or premature. Your documentation must establish why surgery is medically necessary now rather than optional or delayable.

Let me show you how to document orthopedic visits in a way that withstands this scrutiny.

The Orthopedic SOAP Structure That Works

Standard SOAP format works for orthopedics, but certain elements need much more detail than other specialties:

Subjective section: Focus on functional impact, not just pain descriptors. Document what activities the patient can no longer perform and how the condition affects work, sleep, and daily living.

Objective section: This is where orthopedic notes live or die. You need specific measurements (ROM in degrees), strength grading (0-5 scale), special test results by name, gait assessment, and any assistive devices used.

Assessment section: Don't just list diagnoses. Document severity, chronicity, failed conservative measures, and why current intervention is appropriate. This section justifies everything that follows.

Plan section: Insurance wants to see a logical treatment progression. Document what you've tried, what failed, what's next, and why. Include specific goals and timelines.

Let me show you what this looks like in actual practice.

Example 1: Pre-Surgical Evaluation for Total Knee Replacement

Patient: 68-year-old female
Chief Complaint: Severe right knee osteoarthritis, considering surgery
Visit: Surgical consultation

S – Subjective:

Patient presents with 4-year history of progressive right knee pain from osteoarthritis. Pain now constant, rated 7-8/10 at rest, 9-10/10 with walking. Unable to walk more than one block without severe pain requiring rest. Cannot climb stairs without using railing and going one step at a time. Difficulty rising from seated position. Night pain disrupts sleep 4-5 nights weekly despite taking acetaminophen and using ice. Can no longer attend church or shop for groceries independently. Previously active with gardening and walking for exercise, now largely sedentary due to pain. Uses cane for ambulation outdoors and occasionally indoors. Conservative treatment over past 2 years includes: completed 8 weeks physical therapy (limited benefit lasting only 2 months), three corticosteroid injections (each providing 6-8 weeks relief but no longer effective, last injection 4 months ago), trial of meloxicam daily for 6 months (minimal benefit, discontinued due to GI upset), acetaminophen 650mg TID (provides minimal relief), and weight loss of 20 lbs without significant symptom improvement. Patient motivated for surgery, understands risks and recovery timeline, has appropriate social support.

O – Objective:

Vitals: BP 132/78, BMI 29 (improved from 32 one year ago)
Gait: Antalgic gait favoring right leg, using single-point cane
Inspection: Moderate right knee effusion, varus alignment, no erythema
Palpation: Tenderness along medial joint line, no warmth
ROM: Right knee flexion 95° (limited by pain and stiffness, normal 135°), extension lacks 10° (10° flexion contracture)
Strength: Quadriceps 4/5, hamstrings 4/5 (limited by pain)
Special Tests: McMurray test not performed due to limited ROM, patellofemoral grinding positive with crepitus, varus stress demonstrates medial laxity grade 2, no anterior/posterior instability
Neurovascular: Sensation intact, pedal pulses 2+ bilaterally
Standing X-rays (bilateral knees, AP/lateral/merchant views): Severe tricompartment osteoarthritis right knee with near bone-on-bone medial compartment, complete loss of medial joint space, large osteophytes, subchondral sclerosis and cyst formation. Left knee shows mild osteoarthritis for comparison. Varus deformity approximately 8° on standing films.

A – Assessment:

Severe tricompartment osteoarthritis of right knee with significant functional impairment and disability. Patient has exhausted all appropriate conservative treatment options over 2-year period including physical therapy, multiple injections, oral medications, and weight loss without sustained benefit. Current functional status severely limited: cannot walk more than one block, requires assistive device, cannot perform activities of daily living independently, sleep significantly disturbed. Radiographic findings demonstrate end-stage degenerative joint disease with complete cartilage loss and mechanical axis deviation. Patient is appropriate candidate for total knee arthroplasty based on failed conservative care, severe functional limitations, radiographic severity, and patient's desire for surgical intervention to restore function and quality of life.

P – Plan:

Discussed total knee arthroplasty in detail including surgical procedure, hospital stay (typically 1-2 days), recovery timeline (6-12 weeks to functional recovery, 3-6 months to full recovery), extensive physical therapy requirements, and potential complications (infection, blood clots, stiffness, need for revision). Patient understands that surgery will not create a "normal" knee but should significantly reduce pain and improve function. Pre-operative workup ordered: CBC, CMP, PT/INR, EKG, chest X-ray. Medical clearance requested from PCP given age and mild hypertension. Referred to pre-surgical education class. Scheduled for surgery in 4 weeks pending medical clearance. Discussed post-operative expectations including immediate post-op physical therapy, anticoagulation for DVT prophylaxis, and pain management plan. Patient agrees with surgical plan, all questions answered, informed consent process initiated.

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Example 2: Post-Operative Follow-Up After ACL Reconstruction

Patient: 22-year-old male
Chief Complaint: Follow-up 6 weeks after ACL reconstruction
Visit: Post-operative check

S – Subjective:

Patient presents 6 weeks post-op from arthroscopic ACL reconstruction with hamstring autograft (performed for complete ACL tear sustained playing soccer). Reports surgical incisions healing well without redness or drainage. Pain well-controlled, currently 2-3/10 with therapy exercises, takes ibuprofen occasionally. Compliance with physical therapy excellent, attending 3 times weekly and performing home exercises daily. Swelling improved significantly from immediate post-op period but increases slightly after therapy sessions. Able to walk without crutches for past 2 weeks, discontinued crutches at week 4 as instructed. No knee instability, buckling, or giving way episodes. Sleep normal. Eager to return to athletic activities but understands extended timeline required.

O – Objective:

Inspection: Well-healed arthroscopic portal incisions, no erythema or drainage. Minimal effusion. No ecchymosis.
Palpation: Mild tenderness along harvest site, no joint line tenderness, no warmth
ROM: Extension 0° (full), flexion 125° (goal 135°, progressing appropriately)
Strength: Quadriceps 4/5 (hamstring harvest noted), hamstrings 4-/5, improving with therapy
Gait: Normal gait pattern without limp, no assistive device
Special Tests: Lachman test negative/firm endpoint (excellent stability), no anterior translation. Anterior drawer negative. Pivot shift negative.
Neurovascular: Intact
Physical therapy progress notes reviewed: Patient exceeding expected milestones, good quadriceps activation, performing single-leg balance exercises, beginning mini-squats and step-ups.

A – Assessment:

Status post ACL reconstruction (6 weeks), progressing excellently. Surgical site healing without complications. Knee stability excellent with firm endpoint on testing, indicating successful graft incorporation. Range of motion progressing on schedule (flexion typically returns by 8-12 weeks post-op). Strength improving appropriately given hamstring harvest. Patient demonstrating excellent compliance with rehabilitation protocol. No signs of infection, complex regional pain syndrome, or graft failure. On track for typical 6-9 month return to full sports participation timeline.

P – Plan:

Continue current physical therapy protocol, transitioning to strengthening phase with emphasis on quadriceps and hamstring development. Begin closed-chain exercises (leg press, squats) as tolerated. May begin stationary cycling and swimming. No running, cutting, or jumping activities for minimum 3 more months. Follow-up in 6 weeks (3 months post-op) for repeat examination and to assess readiness for running progression. Will perform functional testing at that time. Patient educated on avoiding pivoting activities and importance of continued PT compliance. Discussed realistic return-to-sport timeline of 6-9 months with formal clearance testing required before unrestricted sports participation. Patient understands timeline and remains motivated. Continue taking anti-inflammatory as needed. No restrictions on daily activities or work (patient is student).

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Example 3: Workers' Compensation Lower Back Pain Evaluation

Patient: 45-year-old male
Chief Complaint: Lower back pain after lifting injury at work
Visit: Initial workers' compensation evaluation

S – Subjective:

Patient injured lower back 10 days ago at work while lifting 50 lb box from ground level. Reports immediate sharp lower back pain that has persisted since injury. Pain located in lumbosacral region, radiating into left buttock but not below knee. Rates pain 6/10 at baseline, increases to 8/10 with bending, lifting, or prolonged sitting. Some improvement with rest and ice. No numbness or tingling in legs. No bowel or bladder changes. No lower extremity weakness reported. Sleep disturbed by pain when rolling over in bed. Missing work since injury, works as warehouse associate requiring frequent lifting, bending, and standing. Took ibuprofen with moderate relief for first few days. No previous back injuries or chronic back problems.

O – Objective:

Vitals: BP 128/82
Gait: Slightly guarded but symmetric, no limp, ambulates independently
Inspection: No visible deformity, normal lumbar lordosis, no step-off palpable
Palpation: Tenderness over L4-L5 and L5-S1 paraspinal muscles bilaterally, left greater than right. No midline tenderness. No spasm appreciated.
ROM: Lumbar flexion 60° (limited by pain, normal 90°), extension 15° (limited by pain, normal 30°), lateral bending 20° bilaterally (limited by pain)
Strength: Hip flexion 5/5 bilaterally, knee extension 5/5, ankle dorsiflexion 5/5, plantar flexion 5/5, great toe extension 5/5
Reflexes: Patellar 2+ symmetric, Achilles 2+ symmetric
Sensation: Intact to light touch in L4, L5, S1 distributions bilaterally
Special Tests: Straight leg raise negative bilaterally (pain only in lower back at extreme range, no leg pain), no cross straight leg raise pain. Patrick's test negative. No sacroiliac joint tenderness.
X-rays (lumbar spine, AP/lateral): Normal vertebral body heights, no fracture, normal disc spaces, no spondylolisthesis, normal alignment.

A – Assessment:

Acute lumbosacral strain secondary to work-related lifting injury. Mechanism consistent with musculoligamentous injury. No evidence of neurological compromise: normal strength throughout, reflexes symmetric, sensation intact, negative straight leg raise. X-rays negative for fracture or instability. No red flag symptoms requiring advanced imaging at this time (no bowel/bladder dysfunction, no progressive weakness, no night pain suggesting malignancy, no fever suggesting infection). Injury work-related, patient unable to perform job duties requiring repetitive lifting and bending at this time.

P – Plan:

Conservative management appropriate at this stage. Prescribed cyclobenzaprine 5mg at bedtime for muscle spasm (5-day supply), continue ibuprofen 600mg TID with food. Ice for first 48 hours if not already doing so, then alternate ice and heat. Referred to physical therapy for lumbar stabilization exercises, core strengthening, and proper body mechanics training—critical for preventing re-injury given job demands. Work restrictions: light duty only, no lifting over 10 lbs, no repetitive bending or twisting, may sit/stand alternating as tolerated. Restrictions to be reassessed at follow-up. Expected recovery timeline 4-6 weeks with appropriate treatment and compliance. Follow-up in 2 weeks to reassess symptoms and function. If no improvement by 4-6 weeks or if develops neurological symptoms (leg weakness, numbness, bowel/bladder changes), will obtain MRI lumbar spine to evaluate for disc herniation or nerve root compression. Patient educated on proper lifting techniques, core exercises, and warning signs requiring immediate evaluation. Work status form completed and provided for employer. Case management notified per workers' compensation protocol.

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What Makes Orthopedic Notes Fail Insurance Review

After reviewing thousands of denied orthopedic claims, I've identified patterns that consistently trigger rejections:

Missing Conservative Treatment Documentation

Insurance almost always requires documented failure of conservative care before approving surgery. Your note must explicitly state what was tried, for how long, and why it failed.

Fails: "Patient has knee arthritis, recommend total knee replacement."

Passes: "Patient has exhausted conservative care over 2-year period: completed 8 weeks PT with temporary benefit only, three corticosteroid injections providing diminishing relief (last injection 4 months ago no longer effective), 6-month trial NSAIDs with minimal benefit and GI side effects."

Vague Functional Limitations

Generic statements about pain don't establish medical necessity for expensive procedures.

Fails: "Patient complains of shoulder pain affecting daily activities."

Passes: "Unable to reach overhead to retrieve items from cabinets, cannot dress independently requiring assistance with overhead clothing, sleep disrupted 5 nights weekly due to pain when rolling onto affected shoulder, uses assistive device to bathe."

Objective Findings That Don't Match Complaint Severity

When your exam doesn't correlate with reported symptoms, insurance questions legitimacy.

Watch out for: Patient reporting 10/10 pain but documented exam shows normal gait without antalgic pattern, full ROM, 5/5 strength throughout. This creates doubt about severity.

Better approach: Document specific findings that correlate: "Antalgic gait favoring right leg, ROM limited to 95° flexion (unable to achieve greater flexion due to pain), quadriceps strength 4/5 limited by pain inhibition."

Imaging Ordered Without Clinical Justification

MRIs cost $2,000-3,000. Insurance denies them if your note doesn't explain why imaging will change management.

Fails: "Knee pain, ordered MRI."

Passes: "Positive McMurray test and joint line tenderness concerning for meniscal tear. MRI indicated to evaluate for surgically repairable meniscal pathology versus degenerative changes, which will determine appropriate treatment (arthroscopic repair vs. conservative management)."

Premature Surgical Recommendations

Even when surgery is clearly needed, notes must demonstrate appropriate conservative care was attempted first (unless emergent indication).

Fails: "Patient has rotator cuff tear on MRI, recommend surgery."

Passes: "Partial thickness rotator cuff tear confirmed on MRI. Patient has completed 8-week physical therapy course focused on rotator cuff strengthening and scapular stabilization without functional improvement. Subsequently received subacromial corticosteroid injection 3 months ago providing only 4 weeks relief. Persistent functional limitations and pain despite maximal conservative management now justify surgical consideration."

Documentation Elements That Strengthen Authorization Approvals

After processing thousands of orthopedic prior authorizations through SOAP Notes Doctor, I've learned what dramatically improves approval rates:

Quantify functional limitations with specific activities: Instead of "difficulty walking," document "unable to walk more than 100 feet without severe pain requiring rest, uses cane for ambulation."

Include timeline of conservative treatments: "Failed 12-week physical therapy course (attended 24 sessions), three corticosteroid injections over 18-month period with diminishing returns, 6-month trial of oral anti-inflammatories."

Document impact on work/disability: Insurance responds to economic impact. "Unable to perform job duties as carpenter requiring overhead reaching and lifting, on modified duty for 4 months, employer states no light duty positions available."

Cite radiographic findings specifically: Don't just say "X-ray shows arthritis." State "Standing X-rays demonstrate complete loss of medial joint space with bone-on-bone contact, large osteophytes, and 8° varus deformity."

Include patient's understanding and motivation: "Patient understands surgical risks including infection, stiffness, and need for extensive rehabilitation. Motivated to proceed given current disability and failed conservative care."

Connect dots between symptoms, exam, and imaging: Create coherent narrative where everything aligns. "Patient reports mechanical symptoms of catching and locking (symptom), McMurray test positive with click (exam finding), MRI shows displaced bucket-handle meniscal tear (imaging correlate)."

Orthopedic Documentation Requirements by Procedure Type

Different orthopedic procedures have different documentation expectations:

Joint Replacement (Hip/Knee): Requires severe functional impairment documented, failed 8-12 weeks PT, failed injections, radiographic evidence of severe arthritis, BMI documentation (some insurers deny if BMI greater than 40).

Arthroscopic Surgery: Requires positive physical exam findings correlating with imaging abnormality, failed conservative care (typically 6-8 weeks PT minimum), functional limitations documented.

Spine Surgery: Highest scrutiny. Requires documented neurological deficit (weakness, reflex changes) or severe pain with positive imaging correlation, extensive conservative care failure (PT, injections, medications for 3-6 months minimum), functional disability.

Rotator Cuff Repair: Failed PT (typically 6-8 weeks), failed injection (at least one), MRI confirmation of tear size and quality, documentation of functional limitations affecting overhead activities.

Fracture Fixation: Usually doesn't require pre-authorization but needs documentation of fracture pattern, displacement, stability, why surgical fixation indicated over casting.

How SOAP Notes Doctor Handles Complex Orthopedic Documentation

When orthopedic providers use SOAP Notes Doctor, the system automatically:

• Structures ROM measurements with normal values for comparison
• Includes specific strength grading with 0-5 scale
• Documents special test results by name with interpretation
• Incorporates conservative treatment timelines
• Uses insurance-friendly language about medical necessity
• Creates functional limitation documentation that justifies procedures
• Connects symptoms, exam findings, and imaging into coherent narratives

You record what you found during examination and what you're recommending. The system formats it in a way that maximizes prior authorization approval while remaining clinically accurate.

Try it at soapnotes.doctor and see how it transforms your orthopedic documentation workflow.

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