"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.

14 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. thank you sir for this very helpful information, soon i'll be taking physical therapy board exam.. i hope i could be just like you someday ;)

    ReplyDelete
  6. The Benefits of a Physical Therapy Career include the intrinsic rewards of life as a PTA. In other words, you are helping people each and every day of your career, and having a direct role in. Visit good website for the details.

    ReplyDelete
  7. 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
  8. Physical therapy education prepare people to work with patients who have physical pain or limitations click here for the details.

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

    pl continue the same forever

    ReplyDelete
  10. To become a Physical Therapist you need to pass the NPTE exam which this website can help you with by providing test help, problems, and study guides.

    ReplyDelete
  11. 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

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

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