What is a SOAP note?

There is lots of confusion and controversy, mainly confusion, about what constitutes a SOAP note.
Let’s first look at what insurers require in physical therapists’ documentation:

1. Evidence of Medical Necessity for Physical Therapy
2. Evidence of Skilled Physical Therapy services – that is, the services could not have been provided by a less skilled provider such as an aide, a massage therapist or an athletic trainer.
3. The expectation that the patient will experience significant recovery in a reasonable time frame.

Nagi’s Disablement Model is the preferred model that is disseminated in the Guide to Physical Therapy Practice. The Guide is the professional consensus of what constitutes the standard of physical therapy practice.

With these criteria in mind, let’s look at the SOAP note. What must go in the note?

Subjective
A dis-ability statement, or it’s converse – an ability statement such as the following:
· “I can’t get up out of a chair”
· “I can now get up out of a chair” (satisfies the expectation of improvement criteria)
Don’t use symptom language.
· “My leg hurts”
· “My back hurts’
Symptoms are included in the initial plan of care and, by definition, don’t change much day-to-day in rehabilitative services.

Objective
Numbers.
Measure something. Standardize the measurement. Make sure any other professional in your clinic could repeat the measurement.
· Measure range-of-motion using standardized movements.
· Measure strength using standardized measurements.
· Measure balance using standardized measurements
· Measure fear-avoidance beliefs using standardized measurements.
Make sure the measurements reflect patient-identified goals from the plan of care.

Numbers provide evidence of Medical Necessity for Physical Therapy, which is required in Medicare Progress Notes but not in daily Treatment Encounter Notes. If the daily notes meet the criteria for Progress notes then separate progress notes are not required.

Assessment
Did the patient meet the goal? Are they making progress towards the goals? Did the measurement get better?
· Goal #1 is met (satisfies the expectation of improvement criteria)
· Goal #2 is not met
· Goal #3 is updated. Increase Right Shoulder Flexion in Standing to 180o.

The Assessment also provides the physical therapist the chance to update the physical therapy diagnosis: the link between the patient-identified functional limitations and the measured impairments.

Physical Therapy Evaluation and Re-evaluation is an ongoing component of the skilled service. The initial diagnosis in the plan of care may change as new information is discovered by the physical therapist. The Assessment should be used to integrate the new information with the functional limitations to formulate an ongoing treatment diagnosis.
· Inability to raise the right arm overhead is due to a weak external rotator muscle
· Inability to walk across the parking lot is due to a stiff right hip, a weak right hip external rotator muscle and lumbar instability.
· Inability to descend steps is due to a weak right knee extensor, a right knee flexion contracture and a short calf muscle.

The Assessment should require critical thinking from the physical therapist. The Assessment cannot be done by any other service.

Plan
The Plan updates or changes the plan of care. Most of the time this is done monthly, not daily. The physical therapist updates the plan based on new findings, expected progress or both.

If the Plan is not changed or updated then there is no need to write anything in this portion of the SOAP note.

SIMPLE Template Data Collection

The 'how-to' videos are available at www.Physical-Therapy-Videos.com under the link 'Physical Therapy Diagnosis'.

This template is used for data collection.

The physical therapist puts the data into the plan of care and links the measured impairments to the measured functional limitations (using the OPTIMAL).

The data are impairments in ROM and strength that support the Medical Necessity for Physical Therapy.


SIMPLE Template
SIMPLE measurements-------Right Left Expected Normal (n=151)
1)Standing Trunk Sidebending--------------90 degrees
3)Supine FABER------------------------------22cm
4)Supine SLR----------------------------------65 degrees
5)Supine TKE----------------------------------0 degrees
6)Sidelying Hip External Rotation----------23cm
7)Sidelying Hip Internal Rotation-----------29cm
8)Sidelying Hip Extension------------------0 degrees
9)Sidelying Hip Abduction-----------------10 sec.
10)Sidelying Trunk Rotation----------------9cm

(note: this Word document renders poorly into Blogger so the columns for the Right/Left measurements do not show up well. For the PDF document in Word you can go to www.SimpleScore.com

SIMPLE diagnosis

Which measured values are lower than their expected normal values?

Which measured values are asymmetric?

Can you name the impaired motions?

Goal Setting

Improve [side, position, joint and motion] from [measured value] to [expected value].

How to Write a Medicare Progress Note

As of January 1 2008 re-certifications have to be written every 90 days, up from 30 days in 2007.

Medicare no longer views the physician signed approval of the plan of care as necessary and sufficient to prevent over-utilization. Now, as always, the physical therapist is responsible for providing the appropriate amount of physical therapy services.

The difference now is there will not be a signed note every month from the doctor that ‘tells’ the physical therapist to do physical therapy. There will only be the clinical decision-making of the physical therapist.

When reviewing the physical therapists notes in the chart to determine if the services provided were appropriate, Medicare auditors will look at three things, primarily.


1. Were the services Medically Necessary?

2. Were the services delivered skilled? That is, could a lesser-trained person (such as an aide) have delivered the services at less cost to the Medicare program?

3. Did the patient improve the expected amount in a reasonable time frame?


The physical therapist can write the re-certification note so as to demonstrate these three criteria.

Prior to 2008, many facilities did not distinguish between the Re-certification Note and the Progress Note.

Prior to 2008, the Progress Note was due every ten treatment sessions or once per month, whichever was less.

Prior to 2008, the Re-certification Note was due every ten treatment sessions or every calendar month, whichever was greater.

In 2008, the requirements for the Progress Note have not changed but the Re-certification is now only required every 90 days.

Start the Note

Just as you would in the evaluation, start the Progress Note with a Re-evaluation.

First, measure the Functional Limitations with the OPTIMAL (Outpatient Physical Therapy Instrumented Movement Assessment Log). See this video for the exact way to use the OPTIMAL score sheet.

Specifically, check the patient-identified limitations that they would most like to see improved. Compare them with their initial scores.

Have you set long-term goals using functional limitations? If so, has the patient met their goals?

Next, measure the impairments in range-of-motion that you linked to functional limitations in your initial physical therapy diagnosis. Compare the new measurement with the initial measurements. Did you set goals for these impairments? Did the patient meet their goals?

Finally, check off the goals that have been met and set new goals. If you recommend the patient continue physical therapy then you should set new goals. Remember, you want to demonstrate significant improvement in an expected time frame. The new goal should still reflect the expected time frame you identified in your evaluation.

An Example

For instance, the initial goal was to improve OPTIMAL overhead lifting (frozen shoulder) from a 4/5 to a 2/5. You spent 4 weeks doing stretching and PROM and the patient can now passively range her arm overhead. You might set the new goal to increase external rotator muscle strength from X to Y (see this video for the exact technique to measure external rotator muscle strength).

Now the physical therapist must sign the note. The PTA cannot write the Progress Note. The PT must see the patient at least once during the 10 session treatment period and the Progress Note session is sufficient.