As a practicing physical therapist, it is important to know how to accurately document and record patient visits to ensure appropriate treatment and accurate patient care. To do this, physical therapists use a type of documentation referred to as a soap note. This blog post will provide an example of a soap note specifically for physical therapy visits, including what information should be included and why it is important. Furthermore, it will explain the various components of a soap note and show how to write one for physical therapy visits. The goal is to provide readers with a comprehensive overview of the purpose, structure, and application of soap notes in the physical therapy setting to help ensure the most effective treatment. So, let’s dive in and take a look at an example of a soap note for physical therapy and understand the importance of using this type of documentation.
Benefits of using SOAP notes
The following are some advantages of using SOAP notes to record information for physical therapy patients:
What are SOAP notes in physical therapy?
Healthcare professionals create SOAP notes, which are comprehensive documents, to track a patient’s treatment. A doctor and researcher named Dr. The SOAP method was created by Lawrence Weed as a problem-solving approach to creating patient records. SOAP notes are used by physical therapists to record patient interactions and collect information about their progress during physical therapy. The acronym SOAP stands for four essential parts of patient documentation:
Subjective
The SOAP notes’ subjective section enumerates the patient’s perceptions of their condition, treatment, and progress. When making a diagnosis or monitoring changes in their symptoms, medical professionals can learn valuable information from the patient’s description of their experiences. Information in this section may include:
The subjective section emphasizes how the patients condition affects them. Physical therapists use the information in this section to describe how their patients’ overall quality of life is changed by physical therapy treatments. They might modify a care plan based on subjective data in order to boost patient morale and meet their overall needs.
Objective
Objective data in SOAP notes describes procedures and metrics pertaining to patient care. In this section, physical therapists outline their methods for learning specifics about patients as well as the outcomes of those methods. It is simpler for the physical therapist to track treatment progress when objective information is listed. Here are some examples of data to include in the physical therapy objective section:
Assessment
Physical therapists review patients’ conditions and offer their professional insight on their level of recovery in the assessment section. Physical therapists can look back at previous SOAP notes and note changes to help them create their assessment. This section combines and analyzes data from the first two sections in order to predict a patient’s recovery and assess how well their current treatment strategy is working. The assessment portion of SOAP notes may feature:
Plan
The physical therapist outlines their recommended course of treatment for upcoming physical therapy sessions in the plan section of SOAP notes, which is the document’s final section. The physical therapist outlines the patient’s at-home treatments, recommendations for other professionals, prescribed medications, and schedule for the following in-person appointment. Physical therapists explain each component of their treatment plan and any changes from earlier plans when outlining their strategy.
How to write SOAP notes for physical therapy
To write thorough, useful SOAP notes for physical therapy, follow these steps:
1. Take personal notes
Use shorthand when interacting with patients to quickly record your interactions and observations. Because SOAP notes are comprehensive summaries of a physical therapy visit, they call for concentration and commitment. Making SOAP notes while the patient is receiving treatment may cause both of you to become distracted, so making quick notes or recordings can help you create complete records after the appointment.
2. Identify treatment goals
Start your SOAP notes after a physical therapy session by jotting down your patient’s goals. Goals give the notes useful context, and they make it quick and easy to gauge a patient’s progress. Indicators of effective treatment should be described using precise numbers, such as the ability to lift 15 pounds or walk 100 feet without assistance.
3. Use a narrative format
Use a narrative format to summarize your findings when completing the SOAP note’s main sections. Describe the patient’s experience and what transpires during the appointment in chronological order. Each SOAP note is linked to a larger narrative about the patient’s physical therapy-related recovery thanks to the narrative format.
4. Focus on facts
Be straightforward and unbiased when describing your observations. To avoid making assumptions about a patient or implying judgments about their behavior, attitude, or level of healing, keep your tone neutral. Your SOAP notes will remain accurate as a medical record if you concentrate on the facts of the case, which also enables the care team to make rational decisions.
5. Use precise language
To make it simple for other healthcare professionals to understand the patient’s medical records, include details about the patient’s appointment. Briefly describe each action taken, the tools used, and the methods used to measure it. Give examples to support each claim and carefully check the notes to make sure they make sense. Clarify any unclear language and arrange your ideas to help the reader understand you.
6. File the notes
Add the SOAP note to the patient’s file once it is finished. Record the appointment date and arrange the SOAP notes in time order. The best use of SOAP notes is when you can quickly access them to review how a patient’s physical capabilities alter in response to various treatments.
Template for physical therapy SOAP notes
You can use the following model to direct your SOAP notes:
Date: [Date of the appointment] Provider: [Names of physical therapists and assistants] Diagnosis: [Description of the patient’s current conditions] Patient name: [Patient’s full name]
Describe the precise results you hope to see in the patient during the session in the following sentence.
Plan: [Recommendation for further treatment] Subjective: [Description of the patient’s self-assessment] Objective: [Summary of administered therapies and measurements] Assessment: [Analysis of the physical therapy appointment]
SOAP note example for physical therapy
Use this illustration as a model for creating helpful physical therapy SOAP notes:
*Patient name: Calliope MatthewsDate: May 16, 2021Provider: Dr. Kerry NevesDiagnosis: Healing flexor tendon (post-surgery) in left hand*.
*Goals: Demonstrate average grip strength of over 10 pounds. Complete finger tapping exercises with 80% accuracy. *.
*Subjective: A month after tendon reconstruction surgery, the patient reports a 4/10 overall pain score and an intensifying sensation in their fingers. She claims to perform 30 minutes of radio-carpal abductions every night, take 400 mg of ibuprofen twice daily, and splint her hand when she isn’t doing therapeutic exercises. expresses anger and depression over the inability to use his hands, saying that it is “so depressing” to not be able to play his guitar. ” Denies experiencing nausea, swelling or fever. *.
*Aim: While the patient is seated, apply TENS nerve stimulation to the left hand for 40 minutes, followed by 20 minutes of hand massage and finger mobilizations. three dynamometer grip tests were conducted, with the results showing an average grip strength of 15 pounds at position two. Administered finger tapping instructions and recorded 75% accuracy. *.
*Assessment: The patient shows improving strength and muscle function as a result of following the splinting and exercise instructions. Patient missed mobility recovery benchmark by 5% but shows no other complications to indicate significant recovery delays Constant splint use may contribute to slower mobility improvement. By continuing the patient’s splinting and exercise regimen, they can anticipate steady gains in strength and mobility. May benefit from counseling to handle stress of recovery. *.
Continue performing radio-carpal abductions, and add ten minutes of tendon gliding exercises to your plan. Decrease splinting to nighttime only to promote individual finger mobility. Re-administer finger tapping assessment after one week. Schedule appointment with referred counselor. *.
Physical Therapy Soap Note Example
FAQ
How do you write a SOAP note for physical therapy?
- 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.
- communicating with the patient, their family, and other healthcare professionals
What do you write in a SOAP note?
SOAP stands for Subjective, Objective, Assessment and Plan. Include the components listed by the American Physical Therapy Association in your Physical Therapist SOAP notes to benefit you, your patient, and their entire care team: Patient self-report Details of the specific intervention provided.
What is the assessment part of SOAP note in physical therapy?
A statement about pertinent client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the client’s information (Assessment), and a description of the next step (Planning) are all included in SOAP notes.
