It is essential for physical therapists to keep track of patient information, monitor their progress, and communicate this information with other health care providers to facilitate both interdisciplinary and intradisciplinary care. One common method of documentation that can accomplish these objectives is called the SOAP note.
What do the letters in SOAP stand for and how do you write a SOAP note? We will break the process of how to write a SOAP note into digestible sections in this piece and explain how PTs should go about doing so.
What are SOAP Notes for Physical Therapists
What is a SOAP note? SOAP is an acronym that stands for: subjective, objective, assessment, and plan. These are the four sections that comprise the note.
The main purpose of SOAP notes is that they serve as a standardized documentation format that allows physical therapists and other healthcare professionals to record, analyze, and plan for each patient’s care.
The Significance of SOAP Notes in Physical Therapy
A physical therapy SOAP note is critical because it helps maintain comprehensive records, ensure accountability, and facilitate communication with other healthcare professionals.
Improved note taking efficiency is possible through Electronic Medical Record (EMR)+ software that contains advanced note taking and data management features.
Subjective - Gathering Patient Perspectives
The subjective section of the SOAP note is where the patient’s perspective comes into play.
Collecting Subjective Information
The subjective section allows physical therapists to provide patients with a chance to tell their story. Information within this section may include:
- Patient demographics
- Condition and chief complaint
- History (medical/surgical and family)
- Medications and allergies, social and health habits
- Employment status
- Living environment
- Cultural or religious beliefs
- Other clinical tests such as x-rays or imaging
- Growth and development
- Functional status and activity level
- Response to treatment intervention
- Patient goals.
One good mnemonic to use for the subjective section is OLDCART. Below are the explanations of what each letter stands for, along with examples:
- Onset of the issue: two months ago, patient fell off a curb
- Location: patient hurt the inside of left ankle
- Duration: the pain was intense for three weeks, then tapered and is only present in certain situations
- Characteristics of the symptoms: descriptors such as sharp or dull, tingling, pins and needles, etc.
- Aggravating factors: weight bearing, rolling ankle inward
- Radiating or relieving factors: ice, rest
- Timing: worse in the morning and after doing a lot of activity on feet
Effective communication and active listening are key for mastering the subjective section. Using phrases such as “If I am understanding correctly, you are saying ____,” or attempting to rephrase what they patient has just stated allows for clarification and minimizes the possibility of miscommunication.
Given the volume information that can be placed into a subjective section, formatting these notes in a predetermined template within physical therapy management software can facilitate efficient, effective note taking.
Sample Subjective Information
Below is one SOAP note example of a subjective section that may appear for a follow-up visit of a patient seen for right knee osteoarthritis.
“Patient states that she has done the exercises three times since her last visit. She is having trouble with one of the exercises and is not sure if she is performing it correctly. Pain level in her right knee is a 3/10 today and felt slightly achy this morning. The achiness has decreased as she has moved around more throughout the morning. Squatting and descending steps are still the most aggravating movements, and cause 5/10 pain level. Patient is now able to walk for 10 minutes before she develops any knee pain. She would like to be able to walk up to 30 minutes three times per week for exercise with minimal pain.”
Physical therapy evaluation subjective sections may appear much longer and more detailed, as they would include more of the information covered in the preceding section, such as medications, allergies, and medical history.
Objective - The Concrete Data
While the subjective portion of the note brings the patient’s story to the forefront, the objective section brings precision to your documentation.
Objective Measurement
Physical therapists must gather objective data, including range of motion assessments, strength tests, gait and posture analysis, girth/swelling, wound or incision integrity, special tests, and more.
Precision and consistency in measurements are key. Note the position a patient was placed in for tests and measurements. Consider using a symbol such as an asterisk marked in a key to denote whether a patient experiences pain or discomfort with any objective measurements. These can help to reassess the patient more accurately at the time of progress notes or discharge by ensuring the testing setup is duplicated.
Utilizing Visual Aids
Effective use of visual aids such as graphs and charts can enhance the objectivity of SOAP notes.
For example, including a bilateral manual muscle test (MMT) or range of motion (ROM) chart allows the therapist to utilize MMT grades from 0 to 5 for each muscle or movement. Additional columns may be added to allow the therapist to make other notes on any compensations or check if there is pain while testing certain movements.
Dermatome, myotome, and reflex charts may be placed in the objective section as well. Girth charts for swelling may appear here, too. Make note of the landmarks where the girth is measured, such as the superior and inferior poles of the patella.
If any special equipment is utilized, such as isokinetic testing or force plates for gait and running analysis, the computer-generated graphs can help provide quantifiable information.
These visual aids provide a holistic view of a patient's condition by comparing differences in strength and ROM for certain muscles or movements from one side to another. They also allow for effective comparison between different time points.
Assessment - Clinical Insights
In this section, we'll guide you through the process of clinical assessment.
Analyzing the Data
The assessment section elaborates on the process of assessing a patient's progress and condition using the combined information from the subjective and objective sections.
Some examples of what may be included in this section are:
- Any improvements or deficits in strength, range of motion, or flexibility and how they are impacting a patient’s function, such as their gait.
- Example #1: “Patient demonstrates improved right hip flexor strength, but is still limited in left hip flexor strength, contributing to increased knee flexion in the swing phase,
- Changes in activity tolerance or how a patient has progressed load.
- Example #2: “Patient has improved tolerance to running load, as she was able to run two miles at six miles per hour with no pain today. Prior to this, she could only run one mile at this speed.”
- Example #3: “Today, the patient was able to increase the number of reps from 12 to 15 for all exercises while keeping the same number of sets and the same weights.”
Emphasize the importance of clinical reasoning and critical thinking in the assessment section to help justify the necessity of physical therapy services for improving a patient’s function and meeting their goals.
Goal Setting
Physical therapists establish measurable treatment goals based on their assessment.
Goals should follow the SMART (Specific, Measurable, Achievable, Relevant, Time-bound) framework to meet quality standards and assist in justifying necessary physical therapy services to insurance companies and other healthcare providers.
Plan - Charting the Path to Recovery
The plan section outlines the path to recovery.
Creating a Treatment Plan
The formulation of a treatment plan should encompass specific interventions, modalities, therapeutic exercises, and strategies that will be used to achieve a patient’s goals. Specify any relevant techniques, such as manual therapy and education, that may be provided throughout a patient’s plan of care.
Each patient is different, and individualized plans are needed to tailor to each patient's unique needs. Two patients with the same diagnosis or condition may need different interventions, or varied amounts of certain interventions depending upon their psychosocial, physical, and environmental factors.
Patient Communication
Effective patient communication in the plan section will help patients understand what services physical therapy offers and the types of interventions they can expect to receive throughout their plan of care. This is also a great chance to educate patients on the scope of practice physical therapists hold.
Therapists should ensure patients understand the recommended interventions and are aware of how they should be actively participating in their rehabilitation journey.
Best Practices in SOAP Note Documentation
Effective documentation is the backbone of healthcare.
Timeliness and Accuracy
Timely and accurate documentation is critical for adherence to legal and ethical standards in physical therapy practice.
Legal and Ethical Considerations
Physical therapists must consider the legal and ethical considerations related to patient records and confidentiality. Protected health information (PHI) should not be shared with those who are not involved in a patient’s care. Passwords should be strong and include different characters, capitalizations, and be a certain minimum length for best practice. Do not share access to your documentation with anyone and only access it over secure Wi-Fi so there is less risk of a data breach.
Consider what is relevant to document in the note, as some information the patient provides may not be necessary to include. Do always include information that may impact a patient’s safety and clearly state the actions you took to help the patient and keep them safe. Note whether additional communication with outside resources or providers was recommended to the patient or performed by the physical therapist.
As a healthcare provider, the physical therapist plays a role in safeguarding sensitive information.
Using Note Documentation Software
Utilizing software like PtEverywhere helps physical therapists document SOAP notes and manage patient data to streamline the treatment process. It is incredibly useful for efficiency and practice management as it can help take some of the stress off documenting and shift the focus toward patient-centered care.
Common Errors in SOAP Notes
While SOAP notes are a valuable tool, there are common mistakes that can hinder their effectiveness. Here are some key areas to watch out for:
- Missing Information: Incomplete notes can lead to misunderstandings and hinder patient care. Ensure all essential details are included in each section, following established guidelines for physical therapy documentation.
- Unclear Language: Avoid jargon and medical abbreviations that patients might not understand. Strive for clear, concise, and objective language throughout the note.
- Inconsistencies: Inconsistency in documentation can make it difficult to track patient progress. Maintain consistent phrasing, terminology, and formatting across all SOAP notes.
- Inaccurate Information: Double-check all recorded information for accuracy, including dates, measurements, and medications. Typos and factual errors can create confusion and compromise patient safety.
- Lack of Detail: While avoiding unnecessary information, ensure objective findings have sufficient detail. For example, instead of simply stating "limited ROM," specify the specific joint and the measured degrees of motion limitation.
- Omission of Safety Concerns: Always document any safety concerns raised by the patient or observed during treatment. This includes potential risks associated with specific interventions or limitations in the patient's ability to participate safely.
- Poor Organization: A well-organized note makes it easier for other healthcare providers to navigate and understand the information. Ensure each section (Subjective, Objective, Assessment, Plan) is clearly labeled and follows a logical flow.
By avoiding these common errors, physical therapists can create clear, concise, and informative SOAP notes that effectively communicate patient status and progress.
SOAP Note Efficiency with EMR Software
Electronic Medical Records (EMR) software like PtEverywhere can significantly streamline SOAP note creation. These tools offer features like:
- Templates: Pre-built templates with customizable sections can save time and ensure consistent formatting.
- Macros: Create shortcuts for frequently used phrases or objective findings to expedite data entry.
- Auto-population: EMRs can automatically populate certain fields based on patient demographics or previous visit information.
- Integration with Equipment: Some EMRs integrate with physical therapy equipment, allowing direct import of objective data like range of motion measurements.
- Dictation Tools: Utilize built-in dictation software to capture information verbally, improving efficiency.
PtEverywhere, specifically designed for physical therapists, offers additional functionalities like outcome measure libraries and progress reports, further simplifying SOAP note documentation. These features empower therapists to focus on patient care while ensuring well-documented and comprehensive SOAP notes.
Conclusion
What are SOAP notes? They are a uniform method of documentation within the physical therapy and medical fields that include subjective, objective, assessment, and plan sections. Knowing what each section entails and how to write a SOAP note is essential for clear communication within the physical therapy field.
Mastering SOAP notes can elevate patient care, streamline documentation, and support interdisciplinary collaboration. So, if you've been wondering how to write SOAP notes, we've got you covered! EMR software such as PtEverywhere is useful for simplifying the SOAP note for physical therapists creating clear and concise documentation.