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In case you didn’t know, Physical Therapist SOAP notes are one of the most important tools in your arsenal. What are SOAP notes? These highly detailed notes are used to document patient progress throughout the course of their treatment. While there are many ways a physical therapist can document patient progress, physical therapy SOAP notes are the most comprehensive and structured way to go. These notes are carefully maintained within the patient’s medical records. Detailed patient notes are important as they help keep communication flowing seamlessly between providers. In addition to that, SOAP notes serve to inform the Clinical Reasoning process. According to Physiopedia.com, this is the “process by which a therapist interacts with a patient, collecting information, generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.” SEE ALSO: Top States for PTA Jobs: Salary, Employment Rate, Availability Let’s learn more about how SOAP notes got their origin.
Because the POMR acronym wasn’t quite so catchy, Dr. Weed revised it to SOAP.
SOAP stands for:
The American Physical Therapy Association provides general guidance on what information should be included in Physical Therapist SOAP Notes:
Now that you have a general idea of what a SOAP note consists of, let’s take a more detailed look at each section.
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Physical Therapist SOAP notes include four sections, each with a uniquely important function.
As all health professionals know, it is incredibly important to understand what a patient is experiencing from their point of view. Documenting their subjective experience is crucial because it provides insight into so many aspects of their healing process, such as:
Some patients may not have strong opinions on their treatment, but many do. Notes in this section should also include the patient’s opinions on how and/or why they will overcome their ailment.
When applicable, taking subjective opinions from caregivers and/or family members proves useful as well.
Remember: it’s important to document how the patient perceives their situation without coloring it with your observations or assessments. Your observations come next, and your professional assessment goes in a later section.
The next step in writing SOAP notes focuses on your objective observations.
In this section, the therapist includes detailed notes on current patient status and treatments.
Specifically, therapists should document patient measurements (range of motion, vitals) as well as individual treatment interventions such as:
While this section doesn’t bear as much weight from the legal documentation standpoint, it is highly relevant in the actual treatment of your patient. This section should be specific enough that any other healthcare professional could pick up where you left off.
This section is of high importance when it comes to the legal obligation therapists have regarding documenting patient progress.
Most importantly, you must state and explain your reasoning for all diagnosis and treatments. Make an effort to show:
Whereas the observation section is objective, the assessment section provides the therapist a place to record their professional take on each session.
The final step in writing SOAP notes is documenting the development of your patient’s treatment plan. Specifically, what do you intend to do in future sessions?
Use this area to cover any potential upcoming treatments as well as patient homework before the next sessions.
Even if the next session will be exactly the same, refrain from simply noting “continue with treatment”. Vague SOAP notes won’t help you or your patient’s care team, so take a few minutes to report any steps you plan to cover.
Finally, if you intend to modify your treatment, this is the section to note that.
Let’s take a look at a detailed physical therapy SOAP note example. We’re quoting this one from the book “Functional Outcomes – Documentation for rehabilitation” found on page 125.
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It can take some time to write SOAP notes, but you can now see why it is certainly worth the effort.
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As you can imagine, there are endless benefits for writing SOAP notes. Let’s review some of the main ways these notes will help you:
From a legality standpoint, your Physical Therapist SOAP notes are very specific in nature and can easily serve as proof of your interaction with any given patient.
The written documentation not only covers the basics such as date, time and location but also covers certain details that may become relevant, like the types of treatments you provided, your professional assessments and much more.
As a Physical Therapist, you may work with patients who require an extra level of documentation for legal purposes. For example, those who suffered injuries in an accident caused by someone else, minors, people who are incarcerated, and so on.
Creating a record of detailed treatment notes allows a medical professional to build their own mini-research library. You will note what works, what doesn’t and everything in between.
Writing great Physical Therapist SOAP notes is a tried and true method for collecting data. This data provides reference points throughout a patient’s journey that can help you and your colleagues treat future patients with better accuracy.
Speaking of better accuracy, SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. Your Physical Therapist SOAP notes play a big role in the overall care of a patient who almost always has other providers on their care team.
When it comes down to it, writing SOAP notes gives your patients documentation their other caregivers can use to aid in the healing process. This is especially useful when you are working on a complicated case.
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SOAP stands for Subjective, Objective, Assessment and Plan.
If you want to write Physical Therapist SOAP notes that help you, your patient and their whole care team, include these elements outlined by the American Physical Therapy Association:
Writing SOAP notes ensures everyone involved in your patient’s recovery has the information they need to do the best job possible.
Share them with us in the comments below!
