Thorough and accurate documentation of patient treatments is not only a legal requirement of practicing Physical Therapy but also an important way to keep account of patient progress, communicate to co-treating therapists a detailed plan of care, justify to payor sources that your treatments are medically necessary and provide a defensible document in case your notes become part of a legal case. The SOAP note presents a template for capturing (most) of the essential components of a daily visit and when used correctly, will give you the confidence to master your daily documentation. Sticking only to the components of the SOAP note may result in incomplete documentation in some instances though; read through to the end of this blog to find out when to elaborate a bit more.
What is a SOAP Note?
SOAP stands for subjective, objective, assessment and plan. In general, this formatting prompts the therapist to document the patient’s subjective report, the therapist’s objective findings and interventions, an assessment of the patient’s response to therapy and medical necessity for ongoing care, and the plan for subsequent visits. In this blog you will not only become more clear on the components of each section of the SOAP note but also learn about other things you should always include to ensure your documentation is not incomplete.
This section should include the patient’s self-report of how they are feeling and their response to previous treatment(s). It may be appropriate to include subjective reports of caregivers or care partners here. Some self-report subjective outcome measures may be included in this section as well such as the SF-36 or the ABC.
The objective section consists of 3 distinct components. First, the therapist should document their objective findings made through observing the patient. For example, the therapist may list the patient’s blood pressure or heart rate, document an assistive device utilized by the patient or, describe the quality of movement observed in a particular joint.
Second, this is the section where the therapist should list any objective tests and outcome measures administered to the patient and their results. Manual muscle testing, functional movement screens, and range of motion testing are examples of tests and measures the therapist may list here.
Third, document your interventions here. Provide an account of the treatment provided and any pertinent information about patient response. Include the name of the intervention, number of sets and reps performed, intensity, equipment used (including how much or what type of resistance, if appropriate) and any modifications, cues or assistance provided to the patient. When documenting interventions it is good to think about writing in a way that would allow another therapist to step in and repeat your interventions without difficulty based only off of what you wrote in your note. Being too brief, using too many abbreviations or failing to document the equipment used would make it difficult for another therapist to recreate your treatment.
The assessment section of a SOAP note is where you demonstrate your skill in clinical decision making and problem solving. Simply stating that the patient “tolerated the treatment well” is not going to cut it. This section should include your professional thoughts on how the patient is responding to your interventions, possible precautions or barriers to rehab, remaining impairments and activity/participation restrictions and prognosis for responding to continued care.
Justifying the need for ongoing care is one of the most important components of this section. Patients, physicians and payor sources will be looking to this section to understand how the patient is benefiting from your interventions and why they are or are not making the expected progress. If the patient is not making the expected improvements on the tests and measures you list in the objective section but you fail to explain how extenuating circumstances or unforeseen barriers have impacted patient response you may find your patient’s care being cut short unexpectedly.
In another scenario, if you are confident your plan of care, patient education and interventions have been appropriate but your patient has not been doing their home exercise program and has been cancelling appointments frequently despite (well-documented) conversations with the patient about how this will negatively impact their progress, the assessment section provides a place to explain why you may decide to discharge the patient before they have reached their goals without appearing as though you abandoned your patient needlessly. Your thorough documentation will show their performance on tests and measures across multiple sessions, their level of participation and your efforts as the therapist to educate them on the importance of adhering to the plan of care.
The plan should outline planned future services including interventions or patient education and if any changes to the original plan of care are expected.
Ensuring your Documentation is Complete
While the SOAP note will help you to document most of your daily visit thoroughly, there are a few scenarios to keep in mind that should always be documented but don’t necessarily fit intuitively into the SOAP format. Collaboration or consultation with physicians, care partners, or other providers, for example, should always be documented in the patient’s chart. Additionally, reasons for cancellations and No Shows are important to document as it helps maintain a record of patient participation in therapy and external circumstances impacting their ability to adhere to your plan of care.
Failing to provide evidence of medical necessity and provision of skilled care are the top two reasons for denial of payment. To prove medical necessity, the therapist must document why therapy services are medically indicated at that exact time. Additionally, your notes must reflect why the services of a skilled therapist are necessary to deliver the intervention instead of another provider. How can you do this? Here are a few tips:
● Do not copy and paste the same information across multiple treatment sessions; show that you are individualizing their care each time based off of your clinical assessment
● Document how specific interventions have resulted in progress toward your functional goals
● Document your clinical decision-making around why you prescribed, modified or discharged specific interventions
● Include in your assessment why your plan of care will address the body structure/function impairments and activity/participation restrictions that the patient is currently experiencing.
If you follow these suggestions you can feel confident that your documentation will not only be thorough but will help facilitate consistent reimbursement of your services.
Download our Physical Therapy SOAP Note - Interactive PDF Template to start taking structured progress notes today!
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