CADS I · PT Documentation Learning Coach

From the patient's story to a coherent SOAP note · Seton Hall DPT

Educational use only. Use fictional or fully de-identified cases. Do not enter names, dates of birth, medical record numbers, addresses, or other protected health information. Offline practice checks stay in your browser. The optional AI Clinical Review sends your writing (and a fictional case when attached) to a configured secure server. Do not enter identifiable patient information. AI feedback is formative, not an official grade.

Feedback Studio · Write → Check → Revise

Write your PT note directly in the free-text editor and receive specific feedback that identifies the concern, where it occurs, why it matters, and what you should reconsider. The trainer does not rewrite your note.

Free-text entry only. Use your own SOAP headings and subheadings.

Feedback uses conservative offline rules. An instructor-configured AI service can provide deeper clinical review.

Feedback and revisions

Drafts and checks stay in this browser profile (not your Canvas account).
Write or paste a fictional/de-identified note, then choose Check documentation. Feedback identifies the concern and what to reconsider; it does not generate the corrected note.

Build the note one section at a time

Review the case narrative, identify relevant information, choose appropriate clinical subheadings, free-type your documentation, and receive rubric-based feedback without having the note rewritten for you.

Case text is for reading only; copying is disabled.

How to approach this section

Write your response

Downloads include only your writing, not the patient case or automated feedback. Exchange files containing fictional/de-identified information only.

Write the complete SOAP note

Choose an initial evaluation or daily/encounter note. The reviewer looks at cross-section placement, subheadings, the ICF chain, and note-type expectations.

Case text is for reading only; copying is disabled.

Build a clinical story

Health conditionWhy is the patient here?
ImpairmentsWhat examination findings matter?
ActivitiesWhat tasks are limited?
ParticipationWhat roles or life activities are affected?

Your SOAP note

Use recognizable Subjective, Objective, Assessment, and Plan headings (with or without a colon). Use relevant subheadings within each section. Place Goals within Plan.

Downloads include only your writing, not the patient case or automated feedback. Exchange files containing fictional/de-identified information only.

Review a note from another case

Free-type or paste a fictional or fully de-identified note written outside this app. This review checks SOAP placement, headings/subheadings, Objective formatting, professional language, clinical content, and the ICF story. It will not compare the note with an unrelated case or invent missing patient facts.

Downloads include only your writing, not automated feedback. Exchange files containing fictional/de-identified information only.

Generate another fictional practice case

Create a new offline, template-generated patient narrative. Each case blends subjective interview information, PT examination findings, functional limitations and context into an essay. Students must organize it into appropriate SOAP sections themselves.

Choose the note type and presentation, then generate a narrative.

The offline case generator varies scenarios and measurements but does not call an AI service or the internet. Review new cases for teaching appropriateness before assigning them. Generating a new case replaces the previously generated one, not your writing.

AI Clinical Review · Instructor-style feedback

Use this review after writing your own PT documentation. The AI looks for meaningful omissions, inaccurate placement, imprecise clinical language, and ICF reasoning. It will not write your note for you. This service must be configured by your instructor; the HTML alone does not provide AI review.

Checking for a configured review server…
No practice case attached.

Generated/built-in patient narratives are attached internally when imported from practice; they are never shown as a copyable text field or included in peer-review exports.

Documentation resources

SOAP organization, clinical language, and Objective conventions. Use these while practicing; during a graded Canvas/Honorlock assessment, the instructor can restrict resource access.

Subjective · Complete history

Use appropriate subheadings: HPI, PMHx, PSHx (when known), Medications, Social Hx, Home Environment, PLOF, CLOF, Imaging/Labs (when available), Patient Goals, and relevant patient-reported ROS. When medications are reported, include dose, route and frequency if available; distinguish PLOF from CLOF, including AD use, and describe home access when known. If history, medications, imaging/labs, or home-environment details are not supplied, ask whether they were available or obtained; never invent information or treat missing information as a negative finding. Keep clinician-measured findings in Objective.

Objective · Systems Review

For BP, identify the arm used; for a palpated radial pulse, identify right/left when known. Use a Systems Review subheading for findings actually examined. Do not invent data that are not in the case.

Objective · Tests & Measures

Use subheadings (ROM, MMT, Muscle Length, Joint Play, Gait/Functional Mobility, etc.). Specify side and the accepted test-specific format.

Objective · Interventions

Document what was actually performed, including appropriate dosage, assistance/cueing, education, and patient response.

Assessment · Clinical Impression

Interpret findings using ICF: impairments → activity limitations → participation restrictions, considering contextual factors. Explain clinical significance, rather than copying Objective.

Assessment · Prognosis

State expected maximal function, estimated time frame, services required, and referral needs when appropriate.

Plan · Goals

Goals belong under Plan. For the initial-evaluation assignment, the rubric requires 3 LTGs and 4 related STGs, including the specified ICF levels.

Plan · Interventions

For an initial evaluation, include setting, frequency, duration, and grouped intervention categories. In an encounter note, describe the next steps and progression rather than repeating the full evaluation plan.

Objective section reference

SubheadingRequired documentation elementsIllustration
ROMSide, joint/motion, AROM or PROM, measured range in degrees; full range with extension deficit or hyperextension as appropriateR knee AROM 0–120°; 5° hyperextension: –5–0–135°
Muscle lengthMuscle/test, side, (+) or (−); measurement if (+)R hamstrings (+), knee 30° from extension
Joint playJoint, side, direction, 0–6 gradeR talocrural posterior glide 2/6
MMTMotion, side, MMT gradeR knee extension 4-/5
Functional measureTest or task, result, units, device/assistance as neededTUG 14.2 s without AD

Professional language checklist

Be accurate, concise, specific, and clinically interpretable. Do not mistake a normal word such as “walked” for an error: professional language is about precision in context, not replacing every plain-English verb. Avoid vague statements like “did well” or “tolerated treatment well” without supporting details.

Initial evaluation assignment · 100-point rubric

These are the categories and weights from the course rubric. This learning coach does not assign an official numerical grade.

CategoryPointsExpectations
Subjective10Relevant history, interview, and ROS
Systems Review5Physical examination systems review
Tests & Measures15Impairment- and functional-level examination
Interventions5Details of interventions, education, exercise, and communication
Assessment / PT Diagnosis15Summary and ICF-based problem list
Prognosis5Expected function, time frame, services and referrals
PT Goals (within Plan)153 LTGs (primarily participation), 4 related STGs (ICF-aligned)
Plan of Care10Setting, frequency, duration, grouped intervention categories
Professional Language10Grammar, spelling, medical and GTPTP language, sequencing, terms, abbreviations
SOAP / Patient Management Format10Complete preferred format with correct section placement

The source rubric assigns Excellent, Good (≤2 issues), Fair (≤4 issues), and Below Expectations (>5 issues) bands. Automated comments below are formative indicators, not equivalent to instructor-counted errors.

How the coach reviews writing

It prioritizes clinical content, appropriate SOAP placement, Objective measurement formats, ICF relationships, and clearly vague/nonclinical wording. It intentionally does not auto-grade capitalization or general grammar because rule-based punctuation checks generate false positives in clinical documentation. It cannot confirm the accuracy of a clinical diagnosis, determine whether interventions are appropriate, or fully interpret nuanced grammar. All suggestions need student/instructor judgment.

Drafts are saved only to the current browser profile, not to individual Canvas accounts; on shared devices they are not private. No automatic Canvas Gradebook submission. Copy controls deter ordinary clipboard copying of case material but cannot prevent screenshots or manual transcription.