SOAP Notes – Review Goals & Progress
The Review Goals & Progress section of the SOAP note is designed to track and discuss the patient’s progress toward their treatment goals. This section is completed at every appointment.
There are two main types of goals reviewed in this section:
System-Generated Goals
Based on patient responses to the Global Pain Scale (GPS)Provider-Set Goals
Manually created by the provider in collaboration with the patient
📊 System-Generated Goals – GPS-Based
These goals are created automatically using data from the Global Pain Scale, administered during:
1st appointment
5th appointment (midpoint)
10th appointment (typically the final or pre-discharge appointment)
Goals are based on:
Overall GPS score
Activity section of the GPS
Reported pain medication usage (if any)
Missed workdays due to pain (if any)
Appointment-Specific Actions:
1st Appointment:
Review and document system-generated goals (expect at least 2).
These will become benchmarks for measuring progress in future sessions.
5th Appointment:
Re-administer GPS.
Compare new results to initial goals:
Has pain level decreased?
Has medication use dropped?
Has missed work improved?
If goals were met, new GPS-based goals will be generated.
Review progress and new goals with the patient.
10th Appointment:
Final GPS administration.
Review cumulative progress toward goals.
Document final goal status.
🧑⚕️ Provider-Set Goals (Up to 2)
In addition to system-generated goals, providers can define up to two additional treatment goals. These should be:
Measurable
Specific to the patient's function or symptom relief
Reviewed at every session
✅ Examples:
Improve lumbar flexion from severely limited to full range to support lifting objects.
Reduce pain from 8/10 to 2/10 to allow uninterrupted sleep.
Guidelines:
Review and document status of each goal during every visit.
If a goal is met, you may set a new one, keeping the total active goals at no more than two.
Clearly indicate if a goal has been achieved or modified.
⚠️ Best Practices & Reminders
Review progress collaboratively with the patient at every visit.
Make sure all goals (both system-generated and provider-created) are documented clearly in the SOAP note.
For GPS-related goals, changes occur only when the GPS is re-administered — don’t expect updates every visit.
Keep goals functional and outcome-based to align with clinical documentation standards and support requests for continued care.