Clinical documentation
SOAP documentation guide
How ArkCloud Rehab organises a note into Subjective, Objective, Assessment and Plan, which note types use those sections, and the three ways you can fill them in. You write and sign the note; ArkCloud records what you select and never fills a section for you.
Written for: Physical therapists · Occupational therapists · Speech-language pathologists · Clinic administrators · Evaluators
How a Rehab visit note is organised
The note you write at each treatment visit is the Visit note. It is SOAP-shaped and opens with five sections, all required:
| Section | What goes in it |
|---|---|
| Subjective - patient report | What the patient reports since the last visit. |
| Objective - measurements & observations | What you measured and observed today: range of motion, strength, activity observations. |
| Objective - interventions provided | What you did, so it can be matched to the service billed for the visit. |
| Assessment - response & progress toward goals | Your interpretation of today's findings and the patient's response. |
| Plan - next visit | What happens next. |
Discipline and setting sections follow these five (see How discipline changes the sections). Each section starts empty. A required section left blank does not stop you signing, but it holds the visit from billing as an incomplete note.
Rehab → Episodes → open the episode → Notes → Clinical documentation → New document → Visit note
Which note types use which SOAP sections
Only the visit note is laid out as S, O, A and P. The other note types carry the same clinical content under headings that suit their purpose. The full comparison is on Note types compared.
| Note type | Sections | SOAP-shaped? |
|---|---|---|
| Initial Evaluation | Reason for referral / presenting concern; Relevant history (optional); Subjective - patient report; Objective - examination findings; Functional limitations; Clinical assessment; Measurable goals; Plan of care | Partly. Evaluations started from 1 November 2026 have a Subjective and an Objective section; earlier ones keep their layout, with subjective content in the reason for referral and history and findings in functional limitations and the discipline sections. |
| Visit note | Subjective; Objective - measurements; Objective - interventions; Assessment; Plan | Yes. The only note type with Quick Capture and the AI SOAP draft. |
| Progress Report / Reassessment | Progress toward goals; Reassessment findings; Updated goals (optional); Continued plan of care | No. Reassessment findings hold today's objective measures. |
| Re-evaluation | Reason for re-evaluation; Interval history (optional); Progress toward current goals (optional); Re-assessment findings; Functional limitations (optional); Clinical assessment; Revised measurable goals; Revised plan of care | No. |
| Plan of Care & Goals | Measurable goals; Planned interventions; Frequency & duration; Plan of care | No. It documents the plan, not a visit. |
| Discharge Summary | Course of care; Goals met / outcomes; Discharge status; Recommendations | No. |
Three ways to enter content
Whichever method you use, the text that ends up in the note is the text you put there or chose to insert. The status of each method today:
| Capability | Status | What that means here |
|---|---|---|
| Writing a note yourself | Available | Every note type opens as empty template sections that you type into. Nothing is prefilled, the note saves as you type, and you sign it when it is complete. |
| Quick Capture (structured visit entry) | Available | On a visit note: pain today, what the patient reports, interventions with their focus, treatment activities, AROM/PROM, MMT, tolerance and goal progress, chosen from lists. Nothing is pre-selected and nothing is carried forward from an earlier visit. |
| Build from your selections (no AI) | Available | Turns what you selected in Quick Capture into note sentences with fixed wording, with no AI involved. You insert each section yourself, and the note is not marked AI-assisted. |
| AI-assisted SOAP draft (visit notes) | Available with configuration | Proposes Subjective, Objective, Assessment and Plan text from what is recorded for the visit. The draft appears beside the note; you insert, edit or ignore each section, and signing an AI-assisted note asks you to confirm you reviewed it.Requires: Your organisation's AI switch turned on by an administrator and, where your clinic uses the patient AI agreement, the patient's signed yes to AI-assisted notes. Drafting itself is switched on for the hosted service. |
| Voice-assisted entry | Limited preview | Visit recording and spoken summaries on visit notes, and evaluation recording with proposed entries, are built but not released for routine use. A transcript or proposal never enters a note until you review it and insert or accept it.Requires: Released to an organisation only after clinical, legal and accuracy sign-off. |
| Method | What happens | Where it is offered |
|---|---|---|
| Manual | You type into the sections. On a visit note you can also select from Quick Capture and press Build from your selections (no AI), which writes fixed sentences from your selections for you to insert. | Every note type. Quick Capture and Build from your selections: visit notes only. |
| AI-assisted | Draft SOAP note proposes S, O, A and P text from what is recorded for the visit. You insert each section separately, edit it, or ignore it. Progress reports and discharge summaries have their own narrative draft for named sections. | Visit notes (SOAP draft); Progress Report and Discharge Summary (narrative draft). On an Initial Evaluation, Re-evaluation or Plan of Care there is no whole-note SOAP draft; the AI action beside a field drafts that section. |
| Voice-assisted | A visit recording or spoken summary becomes text in the visit-notes box for you to review; an evaluation recording proposes entries you accept, correct or reject. | Visit notes; Initial Evaluation, Re-evaluation, Progress Report and Discharge Summary. Never the Plan of Care. |
AI drafting is covered in detail on AI-assisted SOAP drafting and voice on Voice documentation. A draft is a proposal: it does not sign, diagnose, decide care or send anything, and well-phrased wording is not evidence that it is correct. If you insert drafted text, signing asks you to confirm you reviewed it, and you are responsible for the signed note.
Document a visit, start to finish
1ArkCloud Rehab
Open the visit note
Written against the visit, one open visit note per visit.
2ArkCloud Rehab
Record with Quick Capture
Pain, report, interventions, activities, measures, tolerance, goal progress.
3ArkCloud Rehab
Check what is still needed
The readiness list names gaps for Assessment and Plan.
4ArkCloud Rehab
Fill the sections
Type, build from selections, or insert an AI draft section by section.
5ArkCloud Rehab
Review and sign
Signing releases the visit's service for billing review.
- Open the episode and start a Visit note from New document, choosing the visit it documents.
- In Document this visit, record what you can from Quick Capture. See Subjective and Objective for each control.
- Read the list of what Assessment and Plan still need, and answer what you can (for example, accept goals or record the patient's response).
- Fill each section: type it, press Build from your selections (no AI), or, where drafting is available, press Draft SOAP note and insert the sections you want.
- Add confirmed body-map and mobility findings if they belong in this note.
- Read the whole note, edit anything that is not what you observed, and sign.
How discipline changes the sections
The episode's discipline adds optional sections after the main ones on every note type. It does not change the note menu. There is no single PT model applied to everyone:
| Discipline | Sections added | Visit-note capture differences |
|---|---|---|
| Physical therapy | Mobility, transfers & gait; Balance; Strength & range of motion; Functional movement | Intervention families for exercise, neuromuscular re-education, manual therapy, gait, therapeutic activity and self-care. |
| Occupational therapy | Occupational profile; Daily activities (ADL/IADL) & participation; Upper-extremity function; Cognition relevant to activities; Adaptive equipment & environmental adaptation | Adds the orthosis section. Hand therapy, neurological rehab and paediatric specialties add their own sections (for example Edema & limb volume, Sensation, Orthotic / splint management). |
| Speech-language pathology | Communication (speech & language); Cognitive communication; Voice & fluency; AAC; Swallowing (when within configured scope) | Adds speech trials with cue levels, speech sounds and swallowing. Offers swallowing and speech-language treatment families alongside exercise, neuromuscular re-education and therapeutic activity; manual therapy, gait and self-care families are not offered. |
| Multidisciplinary | None added | Every intervention family and both the speech and orthosis sections are offered. |
An outpatient episode also adds a Home exercise program section.
Nothing is copied forward silently
A new note does not inherit the last visit's pain score, measurements or findings. Every Quick Capture control starts empty, and a value appears only when you choose it. Where ArkCloud offers earlier information, it is labelled as earlier and you decide what to use:
- Earlier measurements are shown beside today's value as "earlier", never as today's.
- Start from last visit lists the previous visit's activities unticked. Only the rows you tick as done today are added, each marked "started from a previous visit - check the values", and the response is left blank.
- An AI draft labels each source it used as today, standing or earlier, and may not present an earlier number as today's.
Who can write and sign
What this does not do
- It does not generate a note without you. Every inserted section is your choice, and you sign.
- It does not diagnose or interpret. Pick-lists are draft vocabularies awaiting clinical review.
- Choosing a body region does not change the visit note's template or its range-of-motion and strength fields.
- Recording interventions does not create a charge. See Treatment activities.
Troubleshooting
| What you see | Why | What to do |
|---|---|---|
| No Quick Capture or Draft SOAP note on the note | The note is not a visit note (for example an Initial Evaluation), or it is signed. | Use a visit note for a treatment visit. Evaluations are written in their own sections. |
| A message instead of the Draft SOAP note button | Drafting is not available for this organisation or patient. The message says which reason applies. | Write the note or use Build from your selections. Ask an administrator about the organisation's AI setting. |
| The microphone is greyed out with a reason | Voice is a limited preview and not switched on for your organisation, or you lack the recording permission. | Type or select instead. |