"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Monday, January 28, 2008

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.

21 comments:

  1. Very informative and simply put. Wish, it was explained so well during my schooling as OT. I am including this info on my blog with a reference to you.
    Thanks!

    ReplyDelete
  2. This is very helpful. Could you please give more detail about what an assistant should or should not be writing for a soap note?

    ReplyDelete
  3. I'm going to school as a physical therapist assistant and actually in a basic course to explain what physical therapy is all about and this was something that I noticed and has definitely helped me on my way to writing this school report. Thank you so much

    ReplyDelete
  4. Great, glad it helped. What school do you go to?
    Tim

    ReplyDelete
  5. In re: to documenting in the EMR in the acute hospital setting is it imperative that there are 2 notes for BID sessions? Can there be one note with 2 distinct sessions documented? Sorry if not the place for this post.

    ReplyDelete
  6. Physical therapy education prepare people to work with patients who have physical pain or limitations click here for the details.

    ReplyDelete
  7. thank you Dr Tim
    for your valuable notes on SOAP...

    pl continue the same forever

    ReplyDelete
  8. Great points you made there in your article. Thanks, Doctor Tim for all your help, I'm sure a lot of people who want to be a physical therapist will take advantage of your expertise, Thanks for the guidance keep it up.

    Top 7 Chiropractic Websites of 2017 for Medical Students.

    ReplyDelete
  9. SportsCare Physical Therapy can get your life back to normal! Our therapist owned outpatient clinic offers personalized physical therapy and rehabilitation treatment for sports injuries.

    ReplyDelete
  10. This is an excellent post I seen thanks to share it. It is really what I wanted to see hope in future you will continue for sharing such a excellent post. Visit Here

    ReplyDelete
  11. Wow you explained all the stuff in simple word and I liked it. It was nicely stuffed with the material I was looking for. It’s great to be here though by chance.

    ReplyDelete
  12. Amazing and effective proposal by the creator of this blog are truly useful to decrease our hack-tic life. My own particular perspectives are coordinating with creator and I have encountered such. Speech Therapy Doctors in Jaipur

    ReplyDelete
  13. I found your this post while searching for some related information on blog search...Its a good post..keep posting and update the information. Fizikalna terapija

    ReplyDelete
  14. I was very impressed by this post, this site has always been pleasant news Thank you very much for such an interesting post, and I meet them more often then I visited this site. Percussion Therapy

    ReplyDelete
  15. I think this is a really good article. You make this information interesting and engaging. You give readers a lot to think about and I appreciate that kind of writing. Preferred Rehabilitation

    ReplyDelete
  16. Thanks so much for this information. I have to let you know I concur on several of the points you make here and others may require some further review, but I can see your viewpoint. Physical Therapy allen park

    ReplyDelete
  17. Interesting post. I Have Been wondering about this issue. so thanks for posting. Pretty cool post.It 's really very nice and Useful post.Thanks physical therapy billing company

    ReplyDelete

Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"


Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.