SOAP in healthcare stands for Subjective, Objective, Assessment, and Plan. Subjective focuses on pain levels, symptoms, changes, and personal or medical history; objective records measurements, observations, test results, physical examination findings, and other significant data; assessment is the therapist's professional analysis and interpretation of both subjective and objective information, and lastly, plan outlines the recommendations and course of action for the patient promptly detailed by the therapist.
Similar to other branches of the medical industry, SOAP helps greatly in physical therapy due to its organized and systematic approach, enabling clear communication among therapists, holistic assessment, evidence-based practice, flow of care, legal and billing compliance, patient-centered focus, progress tracking, educational value, and contribution to quality assurance.
Here are some tips on how to write effective SOAP notes.
Tips on Effective SOAP notes
Finding the appropriate time to write SOAP notes
Avoid writing your SOAP notes when you are with the patient, it is alright to take notes while assessing the patient but make sure that SOAP is done after the session to avoid taking too long while speaking with the patient, also avoid doing it too long after the session has concluded as it is better to write it while it is still fresh in your mind.
Maintaining a professional tone, keeping it straightforward and being specific
In writing SOAP notes, a physical therapist must ensure that their documentation is written in a professional tone by avoiding slang words; remember that other practitioners and professionals may view this, so it should always be kept in mind. It also helps to keep the writing straightforward and specific to avoid confusion and errors; the shorter it is, the better; making it too wordy may waste valuable space and time.
Avoid biased overly positive and negative phrasing
Sometimes, patients have a condition that severely disables them; in these cases, it is good to avoid phrases that sound biased. For instance, if a patient can’t move a specific body part or feel it, don’t write “the patient can’t even move his arms”; instead, write professionally like “the patient did not move his arms due to being incapable or difficulty of doing so.” That way, you could write specifically without showing bias or sounding judgemental.
Avoid writing subjective statements without proof
The words “very,” “a lot,” and similar expressions that express the severity of what the patient feels or shows do not help in writing SOAP notes. Instead of using those words, you can describe what the patient is feeling through their actions. For instance, instead of writing “the patient was very angry,” you may instead write “the patient expressed frustration and grimaced during the first part of the session.”
Why are Effective SOAP Notes Important?
SOAP notes organize medical documentation and ensure that the information acquired is accurate and consistent. Healthcare professionals need clear communications regarding patient medical records, treatments, and insurance, which is why these notes are crucial.
Elevate Your SOAP Documentation With ScribePT
As mentioned above, SOAP requires specific details crucial to patients' well-being; with ScribePT, your SOAP documentation can be taken to another level with its transcription capabilities. Many tedious processes can be removed through the use of ScribePT; discover how we can help you today!