Complete Guide to Sciatica SOAP Note Examples for Healthcare Providers

If you've ever struggled to document sciatica evaluations in a way that justifies imaging, physical therapy referrals, or specialist consultations, this guide is for you.

I've talked to countless primary care physicians, orthopedists, and neurologists who spend significant time documenting lower back pain and radiculopathy to meet insurance requirements for MRIs, injections, and specialty referrals.

The reality is that sciatica documentation needs specific details that go beyond "patient has back pain."

Insurance companies want to see clear neurological assessments, functional limitations, failed conservative treatments, and evidence that advanced imaging or interventions are medically necessary.

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

In this article, I'll show you exactly how to write sciatica SOAP notes that meet insurance standards, with real examples you can adapt for your practice.

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

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose when managing radiculopathy.

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 sciatica specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of radicular symptoms versus mechanical back pain
• Neurological examination findings supporting nerve root involvement
• Functional limitations and impact on daily activities
• Medical necessity for imaging, injections, physical therapy, or surgery
• Response to conservative treatment measures
• Red flags ruled out (cauda equina, infection, malignancy)

SOAP stands for:

• S — Subjective: What the patient reports about pain location, radiation pattern, aggravating/relieving factors, functional limitations, and symptom progression.
• O — Objective: Your clinical findings including gait, range of motion, straight leg raise, neurological exam (strength, sensation, reflexes), and imaging results.
• A — Assessment: Your clinical diagnosis with dermatomal distribution, severity assessment, and differential diagnoses considered.
• P — Plan: Your treatment plan including medications, physical therapy, injections, imaging orders, specialist referrals, and activity modifications.

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

You're not just recording complaints—you're building a clinical narrative that justifies diagnostic testing and treatment interventions.

How You Can Approach Sciatica SOAP Notes

There's no single correct method for writing sciatica 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 examining the patient. It works if you have strong clinical documentation skills and adequate time between patients. The challenge is that detailed neurological exams are time-consuming to document, and you may inadvertently omit key findings that insurance companies require.

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, ensures you capture all required neurological exam components, and saves significant time on complex musculoskeletal evaluations.

How to Make Sciatica SOAP Notes Faster

One of the biggest complaints I hear from providers managing back pain is how documentation eats into their already limited appointment time.

You've just finished a detailed neurological examination, tested multiple dermatomes and myotomes, performed special tests, and counseled the patient on treatment options—and now you need to document every detail for insurance to approve that MRI.

The pressure is real: make them too brief and insurance denies imaging or physical therapy; make them too detailed and you've just added 15 minutes to every back pain visit.

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
✅ Ensure all neurological exam components are documented

With soapnotes.doctor, you can record during or right after the examination, add rough notes about specific findings, 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 for prior authorizations, but without manually typing every reflex and sensory test.

Maybe you noted specific findings?

"Left leg pain radiating to lateral foot, positive straight leg raise at 45 degrees, weakness with great toe extension, decreased sensation L5 distribution, diminished Achilles reflex."

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

Example 1: Acute Sciatica, New Onset

Patient: 42-year-old male
Chief Complaint: Severe left leg pain radiating down back of leg
Visit: New problem visit

S – Subjective:

Patient reports sudden onset of severe left lower back and leg pain that began 4 days ago while lifting a heavy box at work. Pain starts in left lower back and radiates down posterior thigh to lateral calf and lateral foot. Describes pain as sharp and shooting, 8/10 intensity. Reports numbness and tingling in lateral foot and small toe. Pain significantly worse with sitting, coughing, sneezing, and forward bending. Minimal relief with lying flat. Has been taking ibuprofen 600mg every 8 hours with minimal relief. Denies any bowel or bladder dysfunction, saddle anesthesia, or bilateral leg symptoms. Denies fever, recent trauma beyond the lifting incident, or unexplained weight loss. Unable to work for past 3 days due to pain. Difficulty sleeping due to inability to find comfortable position.

O – Objective:

Vital Signs: BP 132/84, HR 76, Temperature 98.4°F
General: Appears uncomfortable, shifts positions frequently while seated
Gait: Antalgic gait favoring left leg, difficulty with heel and toe walking on left
Lumbar Spine: Paraspinal muscle spasm left side, decreased lumbar lordosis, limited range of motion with forward flexion (fingertips to mid-shin) due to pain, lateral bending and extension limited bilaterally
Special Tests: Straight leg raise positive on left at 45 degrees reproducing radicular pain, negative on right. Crossed straight leg raise negative. Slump test positive on left.
Neurological Exam:

• Motor: Hip flexion 5/5 bilateral, knee extension 5/5 bilateral, ankle dorsiflexion 4+/5 on left (5/5 right), great toe extension 4/5 on left (5/5 right), ankle plantarflexion 5/5 bilateral
• Sensory: Decreased light touch and pinprick sensation over lateral calf and dorsum of foot on left in L5 distribution
• Reflexes: Patellar 2+ bilateral symmetric, Achilles 1+ on left (2+ on right)
• No clonus, negative Babinski bilaterally

A – Assessment:

Acute left L5 radiculopathy (sciatica), most likely secondary to lumbar disc herniation at L4-L5 level based on clinical presentation. Neurological exam consistent with L5 nerve root compression with mild motor weakness and sensory deficits. No red flags for cauda equina syndrome or other emergent pathology. Functional limitations significant with inability to work.

P – Plan:

Medications: Prescribed methylprednisolone dose pack for acute inflammation. Continue ibuprofen 600mg TID with food. Prescribed cyclobenzaprine 5mg at bedtime for muscle spasm. Prescribed gabapentin 300mg, start once daily at bedtime, may increase to TID after 3 days if tolerated for neuropathic pain.
Activity Modification: Discussed avoiding prolonged sitting, heavy lifting, bending, and twisting. Encouraged frequent position changes and short walks as tolerated. Provided work note for light duty restrictions.
Physical Therapy: Referral to PT for McKenzie exercises, core strengthening, and nerve gliding techniques. Start after acute phase subsides in approximately 1 week.
Imaging: Ordered lumbar spine MRI without contrast to evaluate for disc herniation given neurological deficits and functional impairment. If symptoms not improving with conservative management, will need imaging to guide further treatment decisions.
Patient Education: Reviewed natural history of sciatica with most cases improving within 6-12 weeks with conservative treatment. Discussed red flag symptoms requiring immediate evaluation: progressive weakness, bowel/bladder dysfunction, saddle anesthesia, bilateral leg symptoms. Provided handout on sciatica and home exercises.
Follow-up: Return in 2 weeks for reassessment or sooner if symptoms worsen. If no improvement after 4-6 weeks of conservative treatment, will consider referral to spine specialist for evaluation of epidural steroid injection.

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Example 2: Chronic Sciatica, Conservative Treatment Failing

Patient: 55-year-old female
Chief Complaint: Follow-up for persistent right leg pain
Visit: Follow-up visit, established problem

S – Subjective:

Patient returns for follow-up of right-sided sciatica, initially evaluated 8 weeks ago. Reports persistent right buttock and posterior leg pain radiating to lateral foot. Pain intensity improved from 9/10 to 6/10 with current treatment regimen. Completed 6 weeks of physical therapy with modest improvement in flexibility but ongoing radicular symptoms. Currently taking gabapentin 600mg TID and using ibuprofen as needed. Reports numbness in lateral foot persists. Pain worse with prolonged standing and walking more than 15 minutes. Able to return to sedentary desk job but unable to perform usual exercise routine or recreational activities. Denies any new bowel or bladder symptoms. MRI completed 6 weeks ago showed L5-S1 disc herniation with moderate central canal stenosis.

O – Objective:

Vital Signs: BP 128/78, HR 72
Gait: Mild antalgic gait, able to heel and toe walk with difficulty on right
Lumbar Spine: Mild paraspinal tenderness right side, range of motion improved from last visit—forward flexion to mid-shin, extension limited to 50% of normal
Special Tests: Straight leg raise positive on right at 60 degrees (improved from 45 degrees), negative on left
Neurological Exam:

• Motor: Ankle dorsiflexion 5/5 bilateral, ankle plantarflexion 4+/5 on right (unchanged from previous exam), great toe extension 5/5 bilateral
• Sensory: Persistent decreased sensation lateral foot and fifth toe on right in S1 distribution
• Reflexes: Patellar 2+ bilateral, Achilles absent on right (1+ on left, unchanged)
  Review of MRI L-Spine (dated 6 weeks ago): Large right paracentral disc herniation at L5-S1 with compression of traversing right S1 nerve root. Moderate central canal stenosis at L5-S1.

A – Assessment:

Chronic right S1 radiculopathy secondary to L5-S1 disc herniation with nerve root compression, confirmed on MRI. Partial response to conservative management including physical therapy, NSAIDs, and neuropathic pain medications. Persistent neurological deficits including sensory loss and absent Achilles reflex. Functional limitations continue despite 8 weeks of conservative treatment. Patient is appropriate candidate for interventional pain management evaluation.

P – Plan:

Specialist Referral: Referral to pain management for consideration of epidural steroid injection given persistent symptoms and MRI-confirmed nerve root compression despite 8 weeks of conservative treatment. Provided referral documentation including clinical summary and MRI report.
Medications: Continue current gabapentin regimen. May increase to 900mg TID if needed for pain control, monitoring for side effects. Continue ibuprofen as needed for breakthrough pain.
Activity Modification: Discussed pacing activities and avoiding provocative positions. Encouraged continuation of home exercise program learned in PT.
Surgical Consultation: If no improvement after epidural steroid injection(s), will refer to spine surgeon for evaluation of surgical decompression. Discussed that surgery typically considered after 6-12 weeks of failed conservative management when neurological deficits are present.
Follow-up: Return in 4 weeks after pain management consultation, or sooner if new symptoms develop. Will reassess symptoms and determine next steps based on response to injection therapy.

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Example 3: Sciatica Improving with Conservative Management

Patient: 38-year-old female
Chief Complaint: Follow-up for left leg pain
Visit: Follow-up visit

S – Subjective:

Patient returns for follow-up of left-sided sciatica, initially seen 4 weeks ago. Reports significant improvement in symptoms. Pain has decreased from 8/10 to 3/10. Radicular symptoms that previously extended to foot now only present in posterior thigh and upper calf. Numbness in lateral foot has resolved. Completed 3 weeks of physical therapy with good response. Currently taking gabapentin 300mg at bedtime only, discontinued daytime doses. Using ibuprofen occasionally for residual discomfort. Able to return to most normal activities including light exercise and household tasks. Still avoids heavy lifting and prolonged sitting. Sleeping better with minimal nighttime awakening from pain.

O – Objective:

Vital Signs: BP 118/74, HR 68
Gait: Normal, no antalgic component, able to heel and toe walk bilaterally without difficulty
Lumbar Spine: No significant tenderness, range of motion improved—forward flexion fingertips to ankles, extension and lateral bending near normal limits
Special Tests: Straight leg raise negative bilaterally to 80 degrees, no radicular symptoms reproduced
Neurological Exam:

• Motor: Hip flexion, knee extension, ankle dorsiflexion, great toe extension, ankle plantarflexion all 5/5 bilaterally
• Sensory: Light touch and pinprick sensation intact throughout bilateral lower extremities
• Reflexes: Patellar 2+ bilateral, Achilles 2+ bilateral symmetric

A – Assessment:

Left L5 radiculopathy, significantly improved with conservative management. Resolution of neurological deficits. Good response to physical therapy, medications, and activity modifications. No indication for advanced imaging or interventional procedures at this time. Favorable prognosis for complete recovery.

P – Plan:

Medications: Continue gabapentin 300mg at bedtime for another 2 weeks, then discontinue if symptoms remain stable. May use ibuprofen as needed for residual discomfort.
Physical Therapy: Discharge from formal PT. Provided home exercise program focusing on core strengthening, flexibility, and proper body mechanics. Encouraged gradual return to full activities.
Activity Progression: May gradually resume normal exercise routine and activities as tolerated. Continue to use proper lifting techniques and avoid extreme forward bending with heavy loads.
Prevention: Discussed importance of maintaining core strength, flexibility, and proper ergonomics to prevent recurrence. Encouraged weight management and regular exercise.
Follow-up: Return PRN if symptoms recur or worsen. No routine follow-up needed at this time. Instructed to contact office immediately if develops any red flag symptoms including bowel/bladder dysfunction, progressive weakness, or bilateral leg symptoms. Patient verbalized understanding and satisfaction with treatment outcome.

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Key Components Insurance Companies Look For in Sciatica SOAP Notes

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

1. Clear Radicular Pattern Documentation

Describe exact pain distribution following dermatomal pattern (L4, L5, or S1). This differentiates sciatica from non-specific back pain.

2. Comprehensive Neurological Examination

Document motor strength by specific muscle groups, sensory testing, and reflexes. This supports severity and nerve root level involved.

3. Positive Provocative Tests

Document straight leg raise results, crossed straight leg raise, and slump test. These objective findings support radiculopathy diagnosis.

4. Functional Limitations

Specific documentation of how sciatica impacts work, daily activities, sleep, and quality of life justifies treatment intensity.

5. Red Flags Ruled Out

Document that you assessed for and ruled out cauda equina syndrome, infection, malignancy, and fracture.

6. Failed Conservative Treatment

For imaging or specialist referrals, document specific conservative treatments tried, duration, and inadequate response.

Common Mistakes to Avoid

Vague Pain Description: Instead of "leg pain," document "sharp shooting pain radiating from left buttock down posterior thigh to lateral calf and dorsum of foot in L5 distribution."

Incomplete Neurological Exam: Always document motor strength in specific muscle groups, not just "strength intact." Test and document reflexes and sensory examination.

Missing Duration and Progression: Document how long symptoms have been present and whether improving, stable, or worsening.

No Functional Impact: Don't just describe pain—document specific limitations like "unable to sit at desk for more than 20 minutes" or "cannot perform job duties."

Forgetting Red Flag Assessment: Always document that you asked about and ruled out bowel/bladder dysfunction, saddle anesthesia, progressive weakness.

Inadequate Conservative Treatment Documentation: For imaging or referral authorization, clearly document what treatments were tried, for how long, and why they failed.

Tips for Efficient Sciatica Documentation

Use Dermatomal Templates: Create quick reference for L4, L5, and S1 distribution patterns including motor, sensory, and reflex findings.

Standardize Exam Documentation: Develop consistent format for documenting neurological exam to ensure nothing is missed.

Document Comparison to Previous Exams: Note whether findings are improved, unchanged, or worse compared to last visit.

Include Timeline: Always document symptom duration and treatment timeline for insurance justification.

Photograph Patient Drawings: Have patients draw pain distribution on body diagram and include in chart—visual documentation helps with claims.

Final Thoughts

Sciatica SOAP notes don't need to be overwhelming.

They need to be thorough enough to justify diagnostic testing and treatment, but they shouldn't consume excessive documentation time.

The key is having a system that captures essential examination findings and clinical reasoning without making you feel like a scribe instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that supports your clinical diagnosis and treatment plan.

Your time is better spent examining patients and providing effective treatment than struggling with documentation.

That's exactly why we built this tool.

Try it out, see how much time you save on musculoskeletal documentation, and let me know what you think.

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