While there’s no policy that outlines the requirements of basic patient entries, physical therapy practices thrive on a problem-orientated approach to documentation. Physical therapy SOAP notes are a simple, yet detailed, method to document patient progress throughout their treatment and maintain communication between other providers and members of your staff.Here’s a deeper look at the SOAP note meaning and how to write a physical therapy SOAP note.
SOAP is an acronym that’s short for Subjective, Objective, Assessment, and Plan. A physical therapy SOAP note is entered into a patient’s medical record to chronicle each episode of care, share information with other healthcare providers, and inform the clinical reasoning process.Physical therapy SOAP notes record the entire process of a therapist interacting with a patient. A physical therapist SOAP note should log the initial gathering of information, generate a hypothesis about care, and decide on an optimal diagnosis and plan of care (POC) based on the collected information. In other words, these documents chronicle patient intake to patient discharge.A SOAP note is just one of many documentation formats a therapist can use; however, it’s also one of the oldest. SOAP notes were first developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record (POMR), and quickly amassed widespread adoption as the primary method to document and distribute the problems identified by physicians.SOAP notes in physical therapy have also grown in popularity, as this documentation type emphasizes a clear and highly-organized method of logging the natural progression of patient care.Even more, physical therapy SOAP notes act as a roadmap to guide other treatment providers and help fulfill the legal obligation therapists have regarding patient documentation for insurance.
If you’re curious about how to write a SOAP note or are concerned that SOAP charting will take time away from patient care, rest assured that the process is quite simple. In fact, the four sections in a physical therapy SOAP note — Subjective, Objective, Assessment, and Plan — are what dictate the SOAP note format. Take a look at these four sections and the function each has for patient care.
The term ‘Subjective’ implies that the first section in a physical therapy SOAP note is influenced by personal feelings or opinions; in this case, the patient’s. This section is a detailed narrative of what the patient is experiencing from their point of view, including their current condition or complaint, symptoms, activity level, family history, and more.A Subjective section captures a patient’s perception of their functional status, such as:
Notes in a Subjective section should also include relevant medical information obtained from the patient’s chart if the therapist did not directly observe those findings, as well as information from the family or caregivers. Always use quotation marks for direct phrasing from family members or the patient themselves when discussing treatment intervention.
The ‘Objective’ in SOAP notes is the direct opposite of the Subjective. The Objective section in a physical therapy SOAP note should focus strictly on observations that are documented in measurable terms. Both performance-based measures and clinician-reported measures, like the range of motion and vitals, can be included here to help analyze patient progression over time.An Objective section captures a physical therapist’s unbiased observations, such as:
Notes in an Objective section should be specific enough that any other provider, from a physical therapy assistant to a primary doctor, can pick up from where the SOAP note leaves off. These details help quantify the progress towards functional goals and treatment effectiveness.
The ‘Assessment’ in SOAP notes refers to the physical therapist’s reasoning behind the advised treatment protocol. The Assessment is the most important legal note, especially as it pertains to insurance and Medicare compliance because it fulfills the therapist’s legal obligation to document patient progress. It should explain the reasoning behind both diagnosis and treatment.An Assessment section captures the analytical thinking that powered the problem-solving process:
Notes in an Assessment section should expand with each episode of care, as this is the place for a therapist to record their professional opinion of each session. Updates should include patient progress towards indicated goals as well as any positive or adverse responses to treatment.
The ‘Plan’ in SOAP notes outlines the development of a patient’s treatment plan. More specifically, this section should describe what the physical therapist intends to do in future sessions beyond a simple, “continue with the treatment protocol.” Physical therapy SOAP notes should include the anticipated outcomes, planned interventions, and any modifications to treatment over time.A Plan section captures the details of an entire patient plan of care, such as:
Notes in a Plan section should also include recommendations for future care or referrals to other healthcare professionals. Never use vague descriptions to describe treatment protocols while SOAP charting, as this can confuse other providers and ultimately deter patient progress.
Though there are multiple ways to document patient progress, physical therapy SOAP notes offer a simple, structured method that doesn’t take long to include tons of details. Aside from the basic four sections in a SOAP note template, there are additional elements that should always be included within these sections. Here are a few of the details included in a basic SOAP note format.
If you’re anything like most physical therapists, it’s easier for you to learn through examples and try the process yourself rather than read about how it works. If you’re ready to learn how to write a SOAP note for your physical therapy business, this example SOAP note template might help.This is by no means meant to be a complete example but just to give you a sense of things to think about.
Subjective:The patientreports shooting pain in the right lower back. The patient’s partner stated, “It is difficult for him to lift heavy objects or sleep on his side.”
Patient experienced immediate pain symptoms when performing a slump test, right leg (affected) raises 6 inches less than the left leg. SLR test indicated pain symptoms at a 50-degree angle for the right leg.
The patientcontinues to demonstrate pain symptoms under typical sciatica functional measurements. The patient has been compliant with at-home exercises, which has resulted in an increase in range of motion in the affected leg.
The patientis suffering from lumbago with sciatica on the right side. Recommended 12-episode plan of care to see patient weekly. Continue current exercise plan, including piriformis stretch, nerve mobilization stretch, and leg raise, and increase reps to 15. Attempt trunk rotations once the SLR test does not trigger pain symptoms at 50-degrees.
Medicare continues to implement changes to catch up with legislation. There will be substantial financial, operational, and compliance impacts to remain wary of throughout the 2022 calendar year.MWTherapyprovides a full suite of physical therapy software tools to keep your finger on the pulse of all aspects of your practice, including Medicare’s ever-changingcompliancerequirements.
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