The 2026 Guide to Shoulder SOAP Note Examples for Healthcare Providers

If you've ever struggled to document shoulder examinations in a way that captures complex pathology while justifying imaging and treatment, this guide is for you.

I've talked to countless orthopedic surgeons, primary care physicians, and sports medicine specialists who spend significant time documenting shoulder complaints to satisfy insurance requirements for MRIs, physical therapy, and procedures.

The reality is that shoulder documentation needs to be detailed enough to demonstrate medical necessity while being efficient enough to keep up with patient volume.

Insurance companies want to see comprehensive physical examination findings, specific provocative tests, functional limitations, and failed conservative management before approving advanced imaging or interventions.

That's exactly why I built SOAP Notes Doctor to handle the documentation complexity while you focus on accurate diagnosis and treatment.

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

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

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for musculoskeletal 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 shoulder problems specifically, SOAP notes are critical because they demonstrate:

• Comprehensive physical examination with specific provocative tests
• Clear documentation of functional limitations and pain severity
• Appropriate conservative management before advanced interventions
• Medical necessity for imaging studies (X-ray, MRI, ultrasound)
• Justification for physical therapy, injections, or surgical referrals
• Response to previous treatments

SOAP stands for:

• S — Subjective: What the patient reports about pain location, onset, mechanism of injury, aggravating/relieving factors, functional limitations, previous treatments, and impact on daily activities.
• O — Objective: Your clinical findings including inspection, range of motion measurements, strength testing, specific shoulder tests (Neer's, Hawkins, empty can, drop arm, etc.), neurovascular status, and imaging results.
• A — Assessment: Your clinical diagnosis (rotator cuff tear, impingement, frozen shoulder, AC joint arthritis, labral tear, etc.) with severity assessment and differential diagnoses.
• P — Plan: Your treatment plan including medications, physical therapy referral with specific protocols, imaging orders, injections, activity modifications, specialist referral, and follow-up timeline.

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

You're not just recording what you found—you're building a clinical narrative that justifies your diagnostic and treatment decisions.

How You Can Approach Shoulder SOAP Notes

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

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 knowledge of shoulder anatomy and examination techniques and can type efficiently. The challenge is documenting all the relevant special tests, range of motion measurements, and strength grades can be extremely time-consuming, especially when seeing multiple orthopedic patients daily.

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 across different shoulder pathologies, saves significant time on detailed physical exam documentation, and ensures you never miss critical components that insurance companies require for authorization.

How to Make Shoulder SOAP Notes Faster

One of the biggest complaints I hear from orthopedic and sports medicine providers is how shoulder documentation eats into their already packed schedules.

You've just finished a full clinic of shoulder complaints—rotator cuff tears, impingements, frozen shoulders, AC separations—each requiring detailed range of motion measurements and multiple special tests, and instead of moving efficiently through your day, you're buried in documentation.

The pressure is real: make them too brief and insurance denies your MRI order or physical therapy referral; make them too detailed and you've just added an extra hour to your clinic day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate test results
✅ Generate properly formatted SOAP notes instantly
✅ Document complex shoulder exams efficiently

With soapnotes.doctor, you can record during or right after examination, add rough notes about specific findings and test results, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness needed for proper documentation and insurance approval, but without manually typing every range of motion measurement and test result.

Maybe you noted specific findings?

"Forward flexion 120 degrees, limited by pain. Positive Neer's, positive Hawkins, positive empty can. Strength 4/5 with supraspinatus testing. Patient can't reach behind back to fasten bra."

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

Example 1: Rotator Cuff Tendinopathy with Impingement

Patient: 52-year-old male
Chief Complaint: Right shoulder pain for 3 months
Visit: New patient orthopedic evaluation

S – Subjective:

Patient reports gradual onset of right shoulder pain over the past 3 months without specific injury. Pain located at lateral aspect of shoulder, radiating down upper arm. Rates pain 6/10 at rest, 8/10 with overhead activity. Significantly worse with reaching overhead, putting on coat, or reaching behind back. Denies numbness or tingling in arm or hand. Night pain present, difficulty sleeping on right side. Works as a painter with frequent overhead activity. Has tried over-the-counter ibuprofen with minimal relief. Denies previous shoulder injuries or problems. No fever, weight loss, or systemic symptoms.

O – Objective:

Inspection: No visible deformity, swelling, or muscle atrophy. Shoulder contours symmetric.
Palpation: Tenderness over anterior and lateral acromion, bicipital groove tender.
Range of Motion (Right vs Left):

• Forward flexion: 130° (painful arc 70-120°) vs 170°
• Abduction: 120° (painful arc 60-100°) vs 175°
• External rotation: 45° vs 70°
• Internal rotation: L4 vertebral level vs T10

Strength Testing: 4+/5 supraspinatus, 5/5 infraspinatus, 5/5 subscapularis, intact deltoid
Special Tests:

• Neer's impingement sign: Positive (reproduces pain)
• Hawkins-Kennedy: Positive (reproduces pain)
• Empty can test: Positive with pain and mild weakness
• Drop arm test: Negative
• Jobe's relocation test: Not performed (insufficient suspicion for instability)

Neurovascular: Radial pulse intact, normal capillary refill, sensation intact C5-T1 distributions, reflexes 2+ and symmetric
X-ray (Right Shoulder, 3 views): Mild AC joint arthritis, minimal inferior acromial spurring, no fracture, maintained glenohumeral joint space

A – Assessment:

Right shoulder rotator cuff tendinopathy with subacromial impingement syndrome. Clinical examination findings consistent with supraspinatus tendinopathy with impingement. Mild AC joint arthritis noted on X-ray, likely contributing to symptoms. No evidence of complete rotator cuff tear on examination (negative drop arm, maintains some strength). Differential includes partial rotator cuff tear, subacromial bursitis.

P – Plan:

Medications: Prescribed meloxicam 15mg daily for 2 weeks for anti-inflammatory effect. Patient to take with food.
Physical Therapy: Referred for 6-8 weeks of physical therapy focusing on rotator cuff strengthening, scapular stabilization, and posture correction. Home exercise program for range of motion.
Activity Modification: Advised to avoid overhead reaching and heavy lifting during initial treatment phase. Discussed ergonomic modifications at work.
Imaging: Will consider MRI if no improvement after 6 weeks of conservative management to evaluate for partial-thickness rotator cuff tear.
Follow-up: Return in 6 weeks to assess response to physical therapy and medications. Patient instructed to call sooner if symptoms significantly worsen or new weakness develops. Discussed that most cases of impingement improve with conservative treatment. Patient verbalized understanding of treatment plan.

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Example 2: Adhesive Capsulitis (Frozen Shoulder)

Patient: 58-year-old female with diabetes
Chief Complaint: Progressive left shoulder stiffness for 6 months
Visit: Follow-up visit, worsening symptoms

S – Subjective:

Patient reports progressive worsening of left shoulder stiffness over past 6 months. Initially had pain, now predominant complaint is severe stiffness limiting all activities. Cannot reach overhead to get items from shelves, unable to fasten bra behind back, difficulty washing hair. Pain now 4/10, primarily with end-range motion. Severe night pain interfering with sleep. History of right shoulder frozen shoulder 3 years ago that eventually resolved with physical therapy. Type 2 diabetes, well-controlled on metformin. Completed 8 weeks of physical therapy with minimal improvement in range of motion despite good compliance.

O – Objective:

Inspection: No swelling or deformity, mild disuse atrophy of deltoid compared to right.
Palpation: Diffuse tenderness, no specific point tenderness.
Range of Motion (Left vs Right):

• Forward flexion: 85° vs 165°
• Abduction: 70° vs 170°
• External rotation (arm at side): 10° vs 60°
• Internal rotation: Cannot reach behind back vs T8

Strength: 5/5 throughout (limited by range of motion, not weakness)
Special Tests: Unable to perform most tests due to severe restriction. Global capsular restriction pattern present (external rotation most limited).
Neurovascular: Intact, no deficits
X-ray: No fracture, no significant arthritis, normal glenohumeral joint

A – Assessment:

Left shoulder adhesive capsulitis (frozen shoulder), stage 2 (freezing/stiffening phase), significantly limiting function. Patient with diabetes at higher risk for adhesive capsulitis. Failed adequate trial of physical therapy without significant improvement. Interfering with activities of daily living and sleep.

P – Plan:

Injection: Performed intra-articular corticosteroid injection today under ultrasound guidance (40mg triamcinolone + 5mL 1% lidocaine) to reduce inflammation and improve range of motion for therapy.
Physical Therapy: Continue physical therapy with focus on gentle passive stretching and glenohumeral joint mobilization. Aggressive therapy may worsen symptoms.
Home Program: Instructed on pendulum exercises, pulley exercises, and gentle wall walks to perform daily.
Pain Management: Continue current NSAID regimen, may add tramadol for night pain if needed.
Diabetes Management: Emphasized importance of glucose control as this may impact recovery. Patient to follow up with endocrinology.
Follow-up: Return in 6 weeks to assess response to injection and continued therapy. If no improvement, will discuss manipulation under anesthesia versus hydrodilatation procedure. Natural history discussed—may take 12-24 months for full resolution but treatment can accelerate recovery. Patient verbalized understanding.

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Example 3: Acute AC Joint Separation

Patient: 24-year-old male
Chief Complaint: Right shoulder pain after fall
Visit: Urgent care evaluation

S – Subjective:

Patient presents with acute right shoulder pain after falling directly onto shoulder while mountain biking yesterday. Immediate onset of pain at top of shoulder. Reports feeling or hearing a "pop" at time of injury. Pain currently 7/10, worse with any arm movement especially across body. Tried ice and ibuprofen with minimal relief. Denies arm numbness or hand weakness. Able to move shoulder but very painful. No previous shoulder injuries. Right-hand dominant, works as a software engineer.

O – Objective:

Inspection: Visible deformity at right AC joint with prominent distal clavicle, "step-off" deformity present. Moderate swelling and ecchymosis over AC joint.
Palpation: Exquisite tenderness directly over AC joint, intact clavicle on palpation, no tenderness at sternoclavicular joint.
Range of Motion: Limited by pain

• Forward flexion: 90° (guarded)
• Abduction: 80° (guarded)
• Patient able to move shoulder through partial range, resists testing due to pain

Strength: Deferred due to acute injury and pain, patient able to hold arm against gravity
Special Tests:

• Cross-body adduction test: Positive, reproduces severe AC joint pain
• O'Brien's test: Not performed due to acute injury

Neurovascular: Radial pulse 2+, sensation intact, no neurological deficits
X-ray (Right Shoulder with weight-bearing views): Grade III AC joint separation. Coracoclavicular distance 18mm on injured side vs 8mm on contralateral side. Distal clavicle elevated. No fracture.

A – Assessment:

Acute right shoulder Grade III acromioclavicular joint separation. Significant displacement noted on radiographs with >100% increase in coracoclavicular distance. Patient is young, active individual. Will require orthopedic surgery consultation for treatment decision (conservative vs surgical fixation).

P – Plan:

Immobilization: Placed in shoulder sling for comfort and support. Patient to wear continuously except for gentle pendulum exercises.
Pain Management: Prescribed hydrocodone/acetaminophen 5/325mg, take 1-2 tablets every 6 hours as needed for pain. Ibuprofen 600mg every 8 hours with food.
Ice Therapy: Apply ice 20 minutes every 2-3 hours for first 48-72 hours to reduce swelling and pain.
Orthopedic Referral: Urgent referral to orthopedic surgery for evaluation within 1 week. Grade III separations in young active patients often considered for surgical repair, especially if significant cosmetic deformity or functional demands.
Activity: Strict rest, no lifting or reaching with right arm. Off work for at least one week pending orthopedic evaluation.
Follow-up: Patient to see orthopedic surgeon within 5-7 days. Return to urgent care or ED if increasing pain, numbness, or inability to move fingers. Discussed treatment options including conservative management versus surgical repair, final decision to be made with orthopedic surgeon. Patient verbalized understanding and has appointment scheduled.

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Key Components Insurance Companies Look For in Shoulder SOAP Notes

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

1. Detailed Physical Examination

Document specific range of motion measurements (in degrees), strength testing (using 0-5 scale), and results of provocative tests (Neer's, Hawkins, empty can, drop arm, etc.).

2. Functional Limitations

Describe specific activities the patient cannot perform (reaching overhead, behind back, lifting objects, sleeping position). This justifies medical necessity.

3. Conservative Management Attempts

Before approving MRI or surgery, insurance wants documented trials of NSAIDs, physical therapy (with number of sessions), activity modification, or injections.

4. Imaging Progression

Start with X-rays to rule out fracture and arthritis before ordering MRI. Document clinical reasoning for advanced imaging.

5. Provocative Test Results

Specific tests help differentiate pathology: impingement tests, rotator cuff strength testing, stability tests, labral tests. Name the test and result.

6. Response to Treatment

Document what has been tried, for how long, and the patient's response. This builds the case for escalating care.

Common Mistakes to Avoid

Vague Range of Motion Documentation: Instead of "limited ROM," document specific measurements: "forward flexion 120° vs 170° on contralateral side."

Missing Strength Grading: Always use 0-5 scale for strength testing, especially for rotator cuff muscles.

Not Naming Specific Tests: "Positive impingement signs" is less valuable than "Positive Neer's sign and Hawkins-Kennedy test."

Incomplete Conservative Management: Document specific PT sessions attended, medications tried with dosages and duration, and patient compliance.

Forgetting Functional Impact: Insurance needs to know how the shoulder problem affects work, ADLs, and quality of life.

No Comparison to Contralateral Side: Always compare ROM and strength to the unaffected shoulder when possible.

Skipping Neurovascular Exam: Brief documentation that neurovascular status is intact protects against missing serious pathology.

Tips for Efficient Shoulder Documentation

Use ROM Templates: Create templates with normal values that you can quickly modify with actual measurements.

Standardize Your Special Tests: Develop a consistent battery of tests you perform for different suspected pathologies.

Document Bilaterally: Always compare to the opposite shoulder—helps establish baseline and demonstrates abnormality.

Include Pain Scales: Numeric pain ratings at rest and with activity help track progress and justify treatment.

Photograph When Appropriate: Document that photos were taken for deformities or skin changes (AC separation, atrophy).

Reference Previous Notes: When seeing patients for follow-up, compare current ROM and strength to previous visits.

Final Thoughts

Shoulder SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your entire clinic time.

The key is having a system that captures essential examination findings and test results without making you feel like you're spending more time typing than examining.

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

Your time is better spent examining patients and developing treatment plans than struggling with documentation.

That's exactly why we built this tool.

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

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