SOAP notes are highly detailed notes used to document patient progress throughout the course of their treatment.
Let’s learn more about how SOAP notes are used.
What Does SOAP Stand For?
SOAP stands for:
- and Plan.
The American Physical Therapy Association provides general guidance on what information should be included in Physical Therapist SOAP Notes:
- Self-report of the patient
- Details of the specific intervention provided
- Equipment used
- Changes in patient status
- Complications or adverse reactions
- Factors that change the intervention
- Progression towards stated goals
- Communication with other providers of care, the patient and their family
Now that you have a general idea of what a SOAP note consists of, let’s take a more detailed look at each section.
How to Write Physical Therapy SOAP Notes
Physical Therapist SOAP notes include four sections, each with a uniquely important function.
S – Subjective
It is incredibly important to understand what a patient is experiencing from their point of view. Documenting their subjective experience is crucial because it provides insight into so many aspects of their healing process, such as:
- How they feel about their progress
- If they are able to function and on what level
- How/if their quality of life improves over time
Some patients may not have strong opinions on their treatment, but many do. Notes in this section should also include the patient’s opinions on how and/or why they will overcome their ailment.
When applicable, taking subjective opinions from caregivers and/or family members proves useful as well.
O – Objective
The next step in writing SOAP notes focuses on your objective observations.
In this section, the therapist includes detailed notes on current patient status and treatments.
Specifically, therapists should document patient measurements (range of motion, vitals) as well as individual treatment interventions such as:
- Equipment used
While this section doesn’t bear as much weight from the legal documentation standpoint, it is highly relevant in the actual treatment of your patient. This section should be specific enough that any other healthcare professional could pick up where you left off.
A – Assessment
This section is of high importance when it comes to the legal obligation therapists have regarding documenting patient progress.
Most importantly, you must state and explain your reasoning for all diagnosis and treatments. Make an effort to show:
- How you reached your opinion based on the two previous sections
- Why you made the specific treatment decisions based on the patient’s unique problem.
- How you intend to work with the patient on their journey (goals) and any factors that affect these goals.
Whereas the observation section is objective, the assessment section provides the therapist a place to record their professional take on each session.
P – Plan
The final step in writing SOAP notes is documenting the development of your patient’s treatment plan.
Use this area to cover any potential upcoming treatments as well as patient homework before the next session.
Vague SOAP notes won’t help you or your patient’s care team, so take a few minutes to report any steps you plan to cover.
Finally, if you intend to modify your treatment, this is the section to note that.
A Physical Therapy SOAP Note Example
Let’s take a look at a detailed physical therapy SOAP note example. We’re quoting this one from the book “Functional Outcomes – Documentation for rehabilitation” found on page 125.
It can take some time to write SOAP notes, but you can now see why it is certainly worth the effort.
Benefits of Writing Physical Therapist SOAP Notes
As you can imagine, there are endless benefits for writing SOAP notes. Let’s review some of the main ways these notes will help you:
1. Proof of Interaction
From a legal standpoint, your Physical Therapist SOAP notes can serve as proof of your interaction with any given patient.
The written documentation not only covers the basics such as date, time and location but also certain details that may become relevant, like the types of treatments you provided, your professional assessments and much more.
As a Physical Therapist, you may work with patients who require an extra level of documentation for legal purposes.
2. Data Collection for Future Reference
Creating a record of detailed treatment notes allows a medical professional to build their own mini-research library. You will note what works, what doesn’t and everything in between.
This data provides reference points throughout a patient’s journey that can help you and your colleagues treat future patients with better accuracy.
3. Information Sharing Among Peers
SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. Your Physical Therapist SOAP notes play a big role in the overall care of a patient who almost always has other providers on their care team.
These notes provide documentation that other caregivers for this patient can use.
Provide Unwavering Patient Support Through SOAP Notes
SOAP notes are a tool that make it possible to provide only the best support for your patients. What are your favorite tips for writing them?