To write effective SOAP notes as a physiotherapist in Canada, here are some key points to include:
Subjective:The subjective section of SOAP notes summarizes the patient's perception of their condition, care and progress. The patient's description of their experiences can provide useful insights when diagnosing or tracking changes in their symptoms. Information in this section may include:
Patient's chief complaint(s)
Description of symptoms
Pain level and location
Relevant medical history, such as previous injuries or surgeries
Information on the patient's occupation or lifestyle that may be relevant to their condition
Any other concerns or questions raised by the patient
The subjective section emphasizes how the patient's condition affects them. Physical therapists use details in this section to document how physical therapy treatments change their overall quality of life. They may use subjective information to adjust a care plan to support patient morale and address their overall needs.
Objective: Objective information in SOAP notes details actions and measurements related to the patient's care. In this section, physical therapists describe the techniques they use to gather factual information about the patient and the results of their methods. Listing objective details makes it easier for the physical therapist to identify progress with physical therapy treatments. Here are some examples of data to write in the objective section for physical therapy:
Results of any physical examination or testing, including range of motion, strength, joint stability, or neurological testing
Any changes in the patient's physical condition or progress since the previous visit
Any changes in the patient's medication or treatment plan since the previous visit
Any equipment or assistive devices used during the visit
Assessment:In the assessment section, physical therapists review the patient's condition and share their professional perspectives on a patient's recovery status. Physical therapists may reference past SOAP notes and identify changes to develop their assessment. This section combines and analyses information from the first two sections to make projections about a patient's healing and evaluate the success of their current treatment plan. The assessment portion of SOAP notes may feature:
Diagnosis and summary of the patient's condition
Analysis of the patient's response to previous treatments
Evaluation of the effectiveness of current treatment plan
Plan:The last portion of SOAP notes is the plan section, where the physical therapist explains their suggested treatment for future physical therapy sessions. The physical therapist explains therapies for the patient to perform at home, referrals to other specialists, prescribed medications and plans for the next in-person appointment. When describing their plan, physical therapists provide their reasoning for each treatment element and explain any changes from previous plans.
Recommended treatment plan, including exercises, manual therapy, modalities or other interventions
Goals for the patient's recovery and timeline for achieving those goals
Any referrals or consultations needed
Any changes to the patient's medication or treatment plan
Schedule for follow-up visits or tests
Remember that SOAP notes should be concise and to-the-point, and should use clear, objective language. Be sure to document any significant changes in the patient's condition or response to treatment, and to follow your clinic's documentation policies and privacy regulations.
The following was taken from HIROC August 2017 (Strategies for Improving Documentation; Lessons from Medical Legal Claims):
In a case where there is inadequate or missing documentation, the courts will rely on the healthcare provider to testify as to their normal practice. Although this is an acceptable form of evidence, sole reliance on normal practice can significantly weaken the healthcare provider’s case and put their credibility as a witness into question.
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