Treatment Notes and Progress Notes Using a Modified SOAP Format



Treatment Notes and Progress Notes Using a Modified SOAP Format



Treatment notes and progress notes are a key component of physical therapy documentation. In fact, many therapists spend a majority of their documentation time writing these types of notes. Although the focus of this book thus far has been on documenting the initial evaluation, all elements included in treatment or progress notes are essentially components of the initial evaluation. The concepts discussed in the previous chapters all apply here.


Although there are no formal guidelines from either APTA or CMS regarding the structure of treatment or progress notes, such documentation can become unwieldy without some organization. The SOAP note is a commonly used format and is one with which most medical personnel are familiar (see Chapter 2 for the history and development of the SOAP note). The SOAP format is relatively easy to master and provides a quick format for writing a treatment note. This chapter presents a format for writing both treatment notes and progress notes using a modified SOAP format.



Modified SOAP Format


The acronym SOAP stands for subjective, objective, assessment, and plan. This format was discussed briefly in Chapter 2 and is presented here as a framework for treatment and progress note documentation. However, the original design for use of the SOAP note is not how it is currently used by most medical professionals. The SOAP note was designed to promote a sequential rather than an integrative approach to clinical decision making and was linked to the problem-oriented medical record, which is no longer routinely used. However, with some modifications the SOAP note can provide the foundation for efficient, effective functional outcomes documentation in rehabilitation.


The figures and tables in this chapter outline key components of these notes to meet criteria necessary for optimal clinical decision making, third-party payment, and legal purposes. Because treatment notes must serve such diverse purposes, there may be a tendency for therapists to write excessively long notes. Strategies for simplifying documentation are provided in Box 12-1. Furthermore, the case examples at the end of the chapter demonstrate how such notes are modified for different patients in different practice settings.




Treatment Notes


Treatment notes are written for each encounter a PT or PTA has with a patient (Case Examples 12-1, 12-2, and 12-3). Although APTA documentation guidelines and most third-party payers require documentation for each physical therapy encounter, the format of treatment note documentation is at the discretion of each institution.



CASE EXAMPLE 12-1   Treatment Note


Setting: Outpatient


Name: Emily Rodriguez  D.O.B.: 2/3/77  Date of Eval.: 1/5/09





CURRENT CONDITION


31 y.o. female 12 wk postpartum cimage onset of stress incontinence p vaginal delivery of first child.


Goal: Decrease urine losses from 2× daily to 1×/wk.


S: Pt. reports urinary losses of 1 tablespoon have decreased to 1×/day over past 3 days. Occurs primarily when coughing or during physical activities, such as lifting baskets of laundry, running, and jumping. Pt. continues to wear 2 panty-liners daily as continued precaution to protect clothing.


O: Status update: Biofeedback reassessment was completed in supine with noted improvement in EMG activity levels for pelvic muscle contractions. Fair strength of pelvic floor muscle contraction, held 5 sec ×7 reps.


Rx: Pt. performed pelvic floor muscle contractions cimage biofeedback program in the standing position. Pt. performed pelvic floor muscle contractions during a lunge to floor and back to standing, 3 reps each LE (practicing the movement for lifting a laundry basket). Practiced pelvic muscle contractions prior to a cough, 5 reps. Pt. ed: pelvic muscle contraction before cough or lifting heavy objects to prevent incontinence. Revised HEP to ↑ pelvic muscle contractions in sitting for 20 1-sec contractions; followed by 20 min of 10-sec contractions in sitting.


A: Pt. reports decrease in urinary losses over past 3 days, which correlates with observed improvements in EMG activity levels for pelvic floor muscle contractions.


P: Continue PT 1×/wk. Progress with pelvic muscle strength trng and muscle reeducation during functional tasks, with instruction in progressive HEP to improve pt.’s level of ADLs.



CASE EXAMPLE 12-2   Treatment Note


Setting: Inpatient


Name: Wally Narcessian  D.O.B.: 3/7/37  Date of Eval.: 6/20/09 (10:26:00 AM)





Goals




S: Pt. reports not feeling well today, “I’m very tired.”


O: Status update: Auscultation findings: scattered rhonchi all lung fields.


Rx: Chest PT was performed in sitting (ant and post). Techniques included percussion, vibration, and shaking. Pt. performed a weak combined abdominal and upper costal cough that was nonbronchospastic, congested, and nonproductive. The cough/huff was performed with verbal cues. Pectoral stretch/thoracic cage mobilizations performed in seated position. Pt. given towel roll placed in back of seat to open up ant chest wall. Strengthening exercises in standing—pt. performed hip flexion, extension, and abduction; knee flexion 10 reps ×1 set B. Pt. performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over trach when speaking to prevent infection and explained importance of drinking enough water.


A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been compliant with evening exercise program, which has resulted in increased tol. to ther ex. regimen and an increase in LE strength. Amb. not attempted today 2 ° to pt. report of fatigue. Pt. should be able to tolerate short-distance amb. within next few days.


P: Cont. current treatment plan including CPT; emphasize productive coughing techniques; increase strengthening exer reps to 15; attempt amb. again tomorrow.



Treatment notes are written for four distinct reasons:



1. Legal documentation. A treatment note importantly provides a legal record of what was done in a therapy session and why. For this reason, documentation of the specifics of the interventions performed and the patient’s reaction to those interventions is critical.


2. Third-party payment. Third-party payers typically request that treatment notes be provided as proof of service. Medicare, for example, requires documentation to create a record of all treatments and skilled interventions to justify the use of billing codes.


3. To facilitate functional outcomes and clinical decision making. Writing a treatment note that focuses on functional outcomes helps to maintain a therapist’s attention on patient-specific goals. Each treatment note allows the therapist the time to reevaluate the patient’s progress and goals and to consider changes to the plan of care.


4. As a record for other therapists in case of absence. In the event that a therapist is absent, it is important for any covering therapist to have a complete record of the specific interventions that were performed with a patient.



FRAMEWORK FOR TREATMENT NOTE DOCUMENTATION


The framework for treatment note documentation includes goals (G), subjective (S), objective (O), assessment (A), and plan (P) (Figure 12-1).




Goals


From a functional outcomes perspective, the focus of treatment notes should be on the specific goals that are being addressed. Thus the goals should be readily visible to the therapist as he or she writes the treatment note. This can be accomplished by adding a statement at the beginning of the SOAP note that identifies the goals, possibly including only those that were the focus of that treatment (restatement of the goals that were set at the time of the intial evaluation or last progress note). Alternatively, therapists can easily have the patient’s goals reproduced at the beginning of the SOAP note. This can be more easily accomplished using computerized documentation.




Subjective (S)


In the Subjective section of the treatment note, the therapist documents the patient’s subjective respon-ses to interventions and any changes in participation or activity limitations. This section could include any relevant statements or reports made by the patient, patient’s family members, and/or caregivers. The purpose of this section is to detail the patient’s own perception of his or her condition, which can relate to impairments (e.g., pain), activities (e.g., ability to walk), or participation (e.g., ability to work). Box 12-2 provides more information on documenting pain in treatment notes.



This section of the note does not include direct observations made by the therapist. Therapists can report a patient’s or caregiver’s remarks in quotation marks if the exact phrasing is somehow pertinent. Documentation of subjective information should incorporate information that is relevant to the patient’s progress in rehabilitation and specifically related to changes in functional performance or quality of life. It should not include extraneous information that is not directly related to the patient’s current condition.




Objective (O)


The focus of the Objective section is twofold: (1) to document the results of any tests and measures performed, specifically those that relate to achievement of the stated goal(s) (Status Update), and (2) to provide details of the interventions performed (Rx) (see Case Examples 12-1, 12-2, and 12-3). The Status Update should include any examination findings that were performed or observed (e.g., range of motion, walking speed). Documentation of the interventions (Rx) should include the procedural interventions that were performed, including location, frequency, intensity, duration, and/or repetitions, as appropriate. Some of this information can be recorded in table or flowchart form. However, the documentation must clearly show evidence of skilled intervention and the interaction between the patient and therapist (see Chapter 15).


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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Treatment Notes and Progress Notes Using a Modified SOAP Format
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