A brief introduction on SOAP notes
SOAP notes are an essential clinical documentation method to organize your client information efficiently. SOAP notes are an excellent way for any physical therapist to concisely view information and communicate each point of contact you have with your patients. Not only do they allow for this transparency, but they also enable patient data to be accessible to all healthcare professionals to review. Using SOAP notes means your practice can also comply with the law because as a form of progress notes, SOAP documentation provides accountability for healthcare businesses.
For every practice, SOAP notes can look a little different depending on the goals of the business and the needs of their patients. SOAP provides a solid foundation for you to structure your notes but also allows for flexibility. Many business platforms, such as Carepatron, have readymade templates available, so the process of clinical notes is made even more accessible. But to help consolidate your knowledge, this guide will also aid you in making the most efficient observations, so your patients can receive the highest care.
What does SOAP mean in physical therapy?
SOAP notes are a great way to conduct initial evaluations in physical therapy, and there are four essential components you need to include to make efficient notes. While some therapy software outline this process for you, doing it yourself doesn't need to be complicated either.
The core features of a SOAP note include:
Subjective (S) - Consists of the patient's experience and feelings of symptoms and is based on their firsthand account. Evidence includes direct quotes from the patient or third-party members and should be centered around the patient's pain, mobility level, limitations, and improvements.
Objective (O) - Includes factually based observations that demonstrate signs of symptoms. They are free from the physical therapist's influence, bias, and assumptions, and evidence tends to be exercise plans, strength and balance tests, x-rays, vital signs, and other examinations.
Assessment (A) - Using information gathered from the subjective and objective observations, the patient's progress is noted regarding their treatment plan. Amendments to the current plan may be required.
Plan (P) - This is the direct course of action decided by the physical therapist and works towards specific patient goals that target symptoms.
Benefits of writing SOAP notes in physical therapy
SOAP notes also provide immeasurable benefits for not only your physical therapy practice but also for your patients.
Personal data collection - Having a preserved collection of your detailed patient notes means you have a database on various physical issues. With all information regarding patient symptoms and treatments in storage, you can quickly understand what has worked and what hasn't. SOAP notes essentially serve as reference points for you to improve accuracy over time. For example, If a patient shows a similar medical history to another, having the option to compare both documents may highlight new opportunities for improvement.
Evidence of patient interaction - Considering each SOAP note documents the date, time, and details of the physical therapy session, they serve as proof of communication you have with each of your patients. This is especially important for patients who may need additional care when it comes to the documenting process. For instance, those with injuries on behalf of an accident may need detailed proof for insurance or legal purposes.
Ease of information sharing - Because SOAP notes are widely accepted and recognized in the physical therapy healthcare sector, other physical therapists are very familiar with the structure. Due to their universal format, if a patient needs a referral to another healthcare team, they can quickly understand their condition.
How do you write a good SOAP note for physical therapy?
Physical therapy SOAP note pdf
While you now know the basic structure of the , we have included an example of what should be written in further detail to help you avoid missing critical information. This can be integrated into a pdf for your safekeeping.
Physical therapy initial evaluation SOAP note example
Subjective - While noting the patient's experience of their symptoms, it is constructive also to include notes on the patient's opinions on how they will overcome their physical injury or disability. This is in addition to views from close contacts if relevant. Despite this subjective section, you still shouldn't record your input in this process as your assessment comes later.
Objective - These observations should only be notes on the patient's current status, as it is highly relevant in the formulation of your assessment and establishment of your patient treatment plan. This section does not hold much significance from a legal perspective, but the treatment is almost entirely based on these observations injunction with the subjective notes. You should be specific in detail so other physical therapists or healthcare professionals can easily understand your writing.
Assessment - This is the first place for you to inject your professional opinion and judgment on the patient's case. As a result, this section is relevant for legal pursuits, as you must state your explicit reasoning for any diagnoses and treatments. Your rationale should be clear to the reader at all points, and your pathway to a treatment plan should be easily understood.
Plan - As the final step, you should cover what potential upcoming treatments may look like and outline what the patient should be doing outside your clinic. Try to avoid making general statements, even if the next session follows the same procedure as usual. Vague notes don't help your healthcare team, so you should be detailed in any amendments and note specific future goals.
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Physical therapy SOAP note example
To continue solidifying your understanding, we have provided a physical therapy daily note example. This is an example of what a typical physical therapy progress note may look like for your practice.
Subjective
Henry states that he has been feeling low, saying, "I feel exhausted, and it's very draining to do a lot of activity."
Objective
In a sitting position, a chest PT was performed with vibration, shaking, and percussion methods. Henry showed a weak abdominal and upper costal cough of a congested, non-productive, and nonbronchospastic fashion. These were also performed with a VC. Henry also underwent stretch exercises for mobility. These included standing strength exercises of hip flexion, extension, and abduction. Knee reps were 10x1 set. Henry does HEP in the evenings with his caregiver and has been advised to cover his mouth when coughing and to drink water to clear fluids.
Assessment
Henry presents a congested chest and has difficulty with strenuous activity due to coughing. This appears to need the most improvement. His evening HEP has resulted in an increase in LE strength and increased mobility in his exercise regime, and should be able to tolerate short-distance ambulation soon.
Plan
It is best for Henry to continue with the current exercise plan, alongside CBT, and to work on coughing techniques to reduce limitations in coughing productivity. His exercise reps will increase from 15 to 10, and he should attempt ambulation each day to increase mobility. As a result, Henry should begin to feel more revitalized to do return to some activities.
A take-home message for using SOAP notes in physical therapy
Through our examples and explanation, we hope we have strengthened your understanding of SOAP notes for physical therapists, and that you have come to closely understand their importance. SOAP notes are an excellent way to record information from patients, and in a way that holds your business accountable, and allows for easy interpretation from fellow healthcare professionals. They are an essential organizational structure for your practice, and to ensure the highest standard of care for your patients, we recommend their implementation.
Many healthcare business platforms, such as Carepatron, allow for a seamless transition to using SOAP notes, with easy-to-use templates. You can easily work to integrate these into your clinical work with the readily available information from these samples and work to effectively meet your clients' needs. Though, regardless of your choice, SOAP notes are a perfect way to boost the success of your physical therapy clinic.
Further reading:
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