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.