Soap notes

Introduction to Soap notes
each day in the clinic, physical and occupational therapists, physical therapist assistants, occupational therapy assistants, and many other healthcare professionals document what they do with patients. One of the methods they use is a form of patient care note called SOAP note. The soap format for writing notes is not the only methods used in therapy clinics. However, it is very commonly used throughout the country. It would be rare for a therapist or assistant not to encounter the DOAP note format, or one of its variations, during his other career as a student and later as a practicing therapist.

WHAT SOAP MEANS
SOAP is an acronym? Each of the letters in SOAP stands for the name of a section of the patient note. The patient note is divided as follows:

S - Stands for SUBJECTIVE
O - stands for OBJECTIVE
A - stands for ASSESSMENT (analysis)
P - stands for PLAN

TYPE OF NOTES
During the course of a patient's care, the patient is initially assessed, reassessed constantly, and finally assessed upon discharge from the therapist's care. Each of these types of assessment results in a type of SOAP note. An initial note is written after the initial patient assessment. An interim or progress, note is written periodically, reporting the results of reassessment. A discharge not is written when and if therapy is discontinued.

THE ORIGIN OF SOAP NOTES
The SOAP note format was introduced by Dr. Lawrence Weed as a part of a system of organizing the medical record called the problem-oriented medical record (POMR).

Subjective (S)
The subjective part of the note is the section in which the therapist is able to state the information received from the patient that is relevant to the patient's r=present condition. Subjective information is necessary to plan the objective assessment of the patient and to justify or explain certain goals that are set with the patient. For example, third -party payers, utilization review auditors, and quality assurance auditors may question assessing a patient on 16 steps or teaching a patient to go up and down a flight of 16 steps (and why it is taking the patient logger than other patients his age to become independent) Unless the subjective part of the not =e includes documentation that the patient has 6 steps to enter his home.

Categorizing items as Subjective' an item belongs under subjective if

1. The patient (or significant other) tells the therapist or assistant of activates that the patient can no longer perform due to the patient's current condition.

2. The patient (or significant other) tells the therapist or assistant the patient's history

3. The patient (or significant other) tells the therapist or assistant something about the patient's lifestyle or home situation

4. The patient tells the therapist or assistant his or her emotions or attitudes (example: I'm really angry or sad about....)

5. The patient states his or her goals (or the significant other state his or her goals for the patient)

6. The patient voices a complaint

7. The patient reports a response to a treatment (example: increase or decrease in pain intensity)

8. It is anything the patient (or designated significant other) tells the therapist or assistant that is relevant to the patient's case or present condition.

The relevant history obtained from the chart may be stated under the problem (in some facilities, it is stated under O, Objective). It does not belong under Subjective because it is not something that the patient (or significant other) told the therapist directly.

Writing the Objective (O)
The objective part of the note is the section in which the results of measurements preformed and the therapist objective observations of the patient are recorded. Objective data are the measurable or observable information used to plan patient treatment. The testing procedures that produce objective date are repeatable. Objective information written=en in one note can be compared with measurements taken and recorded in the past. It will also serve as a comparative date in the future, as the patient's progress is monitored and reassessed.

Categorizing items into Objective

1. An item belongs under objective if

2. It is part of the patient's history taken from the medical record and relevant to the current problem. Note: only certain facilities include information from the medical record under O.

3. It is a result the therapist's objective measurements or observations (must be measurable and reproducible date; may use date base, flow sheets, or charts and summarize sate here).

4. It is part of the treatment given to a patient (particularly modifications used, number of repetitions tolerated, pain relived or caused) this documentation provide information to anyone who might treat the patient as t what was done in therapy on a certain date. It is also done to inform both those reimbursing the treatment and those who might read the medical record as a legal document of what specifically was done with patient.

5. Patient education activates (particularly specific exercised taught t the patient) Note: many agencies accrediting patient care facility are very interested in written evidence of what we teach our patients and their families.

Abbreviations and medical terminology
Appropriate use of abbreviations and medical terminology is expected, as well as correct spelling. Clarity and conciseness are important.

Writing assessment (A)
The problem list
the problem list includes the major areas that were not within normal limits when the subjective interview and objective testing were performed. It is usually written in list format.

• 1. Prerequisites step
• 2. Review
• 3. Set priorities as to which problem is the most important
• 4. List the physical therapy problems in order of priority.
  
  

Relationship to long and short term goals or expected functional outcomes
usually each problem listed in the note is covered by a long term goal or expected functional outcome. Long term goals are written to describe how each of the problems=s in the problem list will be finally resolved. Expedite function outs comes list the functional level that the patient is expected to reach by the time he or she is discharged for therapy. Therefore expect functional outcome address functional patient problems from the problem list.

Short term goals are part of the assessment portion of the note. They are the inerim steps along the way to achieving longer= term goals (which are the final product of therapeutic intervention) Once the expected final outcomes of therapy (long term goals) have been determined, the short term goals are then set. The specific treatment regimen is designed to achieve the short term goals.

• 1. Plan
  The Plan must include the flowing information:
  Frequency per day or per week that the patient will be seen (or the total number of visits that the therapist will see the patient)
• 2. The treatment the patient will receive
  

Also frequently include are the following:

• 1. The location of the treatment
  the treatment progression
• 2. Plans for further assessment or reassessment
• 3. Plans of discharge
  patient and family education
• 4. Equipment needs and equipment ordered for or sold to the patient
• 5. Referral to other service; whether there are plans to consult with the patient's physician regarding further treatment or referral.
  

Interim notes and discharge summaries
in the interim note, a problem is usually only listed if it is a new problem. If it has been resolved, or if you are referring to the problem. When writing the discharge summary, it is important to note whether a problem has been resolved or still exists.

Summary
While the problem list is not included in the notes of every facility, it is an important part of planning for patient care. It summarizes the information reported in the S and O sections. Judgment is involved in writing the problem list. It helps the therapist to set priorities. It becomes the basis for goal setting.