Physiotherapy (PT) SOAP notes writing is an important part of physiotherapy practice. Following proper PT recording of every patient or client encounter should be practiced to avoid confusion or delays in reimbursements.
The physiotherapy SOAP notes, sometimes called daily notes or progress notes, is the documentation done for every patient physiotherapy visit following the comprehensive PT initial evaluation (IE). The daily SOAP notes will indicate whether a particular plan of care is benefiting the client or not or treatments need to be modified.
Parts of the Physiotherapy SOAP NOtes / Daily Notes
Every physiotherapy SOAP notes should include basic information such as the client's full name and identification number is included if applicable. The full name of the physiotherapist, proper designation, such as PT, DPT or MPT and signature should be included as well. The date of treatment or encountered should always be included.
The subjective part of the SOAP note is where you write what your client has to say about his or her current condition. For example, "I can now bend my back to put on my socks and shoes following my treatment session yesterday."
It is better if the patient's subjective statement is more specific. For example, "The pain on my back has moved down to 3/10 from that of yesterday before my treatment."
The "objective" part includes all the measurements that you've obtained from your client. This include the vital signs (e.g. BP-blood pressure, To-temperature, HR-heart rate, and RR- respiratory rate), manual muscle testing measurements, joint range of motion measurements, etc.
The specific physiotherapy treatments are also included in the objective part of your SOAP note. The treatments provided should be specific enough so as another PT can provide treatment if the treating physiotherapist is out for the day. The treatment should include the specific weight, repetitions, intensity and duration whenever applicable.
- ® Knee extension, full ROM, 10 reps, 3 sets with 5 lbs. ankle weight
- HMP on bilateral lumbar area x 20 minutes
This is where the physiotherapist impression regarding patient's current situation since his or her last visit. This may also include the physiotherapist's perspective on whether a particular treatment will be continued or modified according to client's needs.
Example: "The patient tolerated the treatments well but patient needs frequent verbal cues from the physiotherapist to complete knee exercises at full range."
In the SOAP plan part, the physiotherapist writes the plans for the client's next physiotherapy visit. This may include the objectives, treatments, progression parameters, and precautions.
Related Topics from other WebSites:
- All About SOAP Notes. Physical Therapy (PT) Notes
- Guidelines: Physical Therapy Documentation of Patient/Client Management. American Physical Therapy Association (APTA)
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