May 9, 2024 | Net Health

11 min read

What Is a SOAP Note?

The Key to Enhancing Communication, Engagement in Rehab Therapy

In the complex world of healthcare, documentation is critical in patient care, clinical coordination, and optimizing payer reimbursements. In rehab therapy, SOAP notes form the backbone of these efforts and an essential aspect of rehab therapy documentation.

SOAP is an acronym based on each of the note’s four components:

  • Subjective: The patient’s feelings about the issue and how it impacts his/her life.
  • Objective: The rehab therapist’s objective observations and measurements.
  • Assessment: An analysis of the information gleaned by the rehab therapist during assessments.
  • Plan: The plan of care (POC) and how it will help the patient reach his/her goals.

As part of a patient’s official medical record, a SOAP note is an essential tool that provides a simple yet thorough methodology for practitioners to document patient visits, from descriptions of ailments and injuries to establishing and tracking one’s POC.

What is the Purpose of SOAP Notes?

Consistently recording medical information and detailed patient information (such as patient’s age, vital signs, patient’s symptoms, current medications, healthcare provider, present illness, patient’s chief complaint, etc) enables rehab therapists to continually measure progress based on the patient’s response to treatments.

This fulfills several purposes:

  • Legal requirement for practicing rehab therapy in the U.S.
  • Process for tracking patient progress in an accountable way.
  • Way to communicate with other rehab therapists and healthcare professionals about a detailed plan of care.
  • Method for justifying to payers that a patient’s treatments are medically necessary.
  • Defensible way to document in cases where notes may come into legal question.

We’ll take an in-depth look at SOAP notes—what they are, how they’re organized, and what type of information must be included within each section for notes to be considered thorough and complete.

But first, a brief history lesson.

The History of SOAP Notes

The SOAP note was originally developed over 50 years ago by Dr. Lawrence Weed, a physician and educator at the University of Vermont. Concerned with the lack of consistent documentation within the medical field, Dr. Weed created the methodology so healthcare providers could document in a structured, organized, and consistent way.

While rehab therapists have largely adopted the use of SOAP notes, no policy actually exists outlining specific requirements for basic patient documentation. This lack of a consistent note-taking structure can create confusion between practitioners and disrupt care coordination, potentially negatively impacting patient experiences and outcomes.

In today’s tech-based, data-driven world, healthcare providers are not the only ones who access a patient’s medical record. Information within a SOAP note is often accessed by patients via patient portals, billing and legal professionals, administrators, and researchers. As patients interact with medical notes differently, some healthcare professionals have questioned the long-term utility and effectiveness of these notes in today’s world.

As it stands now, they continue to be the standard by which most rehab therapists document patient encounters.

SOAP notes physical therapy
Doctor hands, book and writing at desk, documents or review for report, results or ideas for healthcare. Medic, notebook and pen for paperwork, compliance and insurance info with schedule in hospital.

The Structure of Soap Notes and SOAP Format

According to the American Physical Therapy Associaton (APTA), a completed SOAP note should contain descriptions of all of the following information:

  • Self-reporting and perspectives from the patient
  • Details of the specific treatments and interventions provided
  • The equipment used during assessments and treatments
  • Any changes in the patient’s status
  • Complications or adverse reactions to treatments and interventions
  • Factors that alter interventions or the plan of care
  • How the patient is progressing toward their stated goal
  • Communication and collaboration efforts with other providers

In documenting this information within a SOAP note, healthcare providers must also record the clinical reasoning behind the decisions they make—for example, why a specific intervention was prescribed, modified, or replaced during the POC.

It’s also critical that the medical notes offer insight into how the chosen course of action will address the functional impairments and mobility/activity restrictions the patient is experiencing.

Finally, always write a SOAP note assuming that it will one day be read by another healthcare professional. This may be someone within your own organization trying to pick up where you left off, or it could be a practitioner in another field reviewing medical history during a future patient encounter. It’s a professional courtesy and responsibility to ensure each SOAP note is well-written.

How does each section of a SOAP note help tell the patient’s story clearly, consistently, and comprehensively? Let’s take a look.

Subjective (S)

The Subjective section of a SOAP note captures the patient’s story from their perspective. What is their chief complaint? It’s largely based on the patient’s own words and feelings about his or her current condition, often using terms and phrasing quoted directly from the patient to provide context for why the patient is visiting a rehab therapist.

In capturing this valuable perspective, the provider should include the patient-reported description of their symptoms, pain levels, and functional limitations. This may involve information related to family history and living environment as well as social determinants of health—things like eating and sleep habits, economic stability, community support systems, and other potential stressors. It may also include family history, medical and surgical history, relevant client behavior, social history, and more.

Finally, and perhaps most importantly, this section is where the provider records the specific goals the patient wishes to achieve by visiting a rehab therapist. Do they want to increase mobility, reduce pain, or improve performance in an activity? How will they define success, and what specifically do they most look forward to doing once they improve (working, parenting, playing a sport, aging in place, etc.)?

Errors to Avoid in the Subjective Section

Patient perspective is critical in the subjective section of a SOAP note, so avoid recording your interpretation of what they say or passing judgment on the patient. Take the patient at her or his word and record what they say accurately.

When doing so, also avoid noting information that’s irrelevant to the issue at hand, as your subjective and objective sections should strike a balance between informative and succinct.

Objective (O)

In a SOAP note, the Objective section is where the rehab therapist records patient data and factual information that she or he observes, measures, and tests. This may include range-of-motion measurements, strength or balance assessments, functional movement screens … essentially any assessment that produces quantifiable data that can be observed independently of the patient’s feelings or input.

Recording this information in your patient notes helps practitioners further assess the patient’s condition. It also provides a point of reference for tracking progress, positive or neutral, during future appointments.

Such comparisons will help clinicians determine the effectiveness of treatments and how well interventions are helping patients progress toward their goals, or if different treatments may be necessary.

Errors to Avoid in the Objective Section

The most significant error one can make in this section is to skimp on important details. This includes using global summaries (like home exercise plan exercises prescribed) for interventions that could use additional specificity.

Though assessments may lead practitioners down seemingly obvious and familiar paths, detailed data is necessary for measuring progress and communicating with colleagues and other medical professionals should follow-up care be required.

Assessment (A)

Though the word assessment was used more generally in the previous two sections, the “Assessment” section carries specific expectations within the SOAP note format.

Assessment notes consider information from both the Objective and Subjective sections to form the rehab therapist’s judgment about the patient’s current condition. This may include a diagnosis, progress notes, and any changes to the patient’s condition since the last visit.

This section should also include the reasoning behind the rehab therapist’s decisions, clarifying and supporting the problem-solving process that led to the current plan of care. Has progress been made toward the patient’s goal, or are changes necessary in the frequency and duration of treatments? Does a lack of consistent progress indicate a new intervention is needed? All this should be noted within this section.

Errors to Avoid in the Assessment Section

Avoid being vague in your assessments. Stating that a patient is “making progress” or “on track toward goals” is not enough relevant patient information. Be specific about how these conclusions are being determined, providing insight as to what it means for the patient and his/her treatment plan.

Plan (P)

This final section of the SOAP note format outlines the proposed strategy for future management of the patient’s condition. This includes therapeutic interventions, frequency of therapy, patient education strategies, anticipated outcomes, and goals for improvement.

The Plan is essential for guiding ongoing treatment and setting expectations for recovery. It documents referrals to other healthcare providers and recommendations for future treatments and follow-up care. This includes details about patients’ HEPs and any changes in the direction of care.

Errors to Avoid in the Plan Section

As with other sections, the biggest mistakes clinicians can make when recording plans involve being too vague—or not indicating an upcoming plan at all. This can happen when treatments are progressing as expected, causing some clinicians to think a notation like “Recommend continuation of treatment” will suffice.

Instead, write case notes that offer insight into the patient’s successes and how this impacts the plan of care. If the patient was compliant with the prescribed HEP, for example, note this.

physical therapist filling out SOAP notes on an iPad

Writing Effective SOAP Notes

Writing effective SOAP notes is a critical skill for rehab therapists. It not only enhances the quality of patient care but also ensures that documentation meets clinical and legal standards.

Here’s how therapists can master the art of writing SOAP notes, while also improving patient outcomes in rehab therapy.

SOAP Note Best Practices

Creating concise, clear, and comprehensive SOAP notes is an art that comes with practice and attention to detail. Here are some best practices for therapists to consider.

  • Be Concise and Specific: While details are important, brevity is key. Avoid unnecessary jargon and lengthy descriptions that do not add value to the patient’s record. Each entry should be concise and to the point, focusing on relevant information only.
  • Use Objective Language: Ensure that the notes are objective, especially in the Objective and Assessment sections. Use measurable data and observable facts to support clinical assessments and treatment plans.
  • Consistency is Key: Maintain a consistent format and level of detail in each note. This consistency helps other healthcare providers quickly understand and follow the patient’s progress and treatment plan.
  • Incorporate Standardized Tools: When possible, use standardized measurement tools and scales to describe symptoms and progress. This can include pain scales, range of motion measurements, and standardized functional assessments.

Common Pitfalls to Avoid

Even experienced therapists can fall into common pitfalls that reduce the effectiveness of SOAP notes. Here are some to watch out for.

  • Vagueness: Avoid vague terms and phrasing like “progressing” or “fell short of expectations” Instead, use specific descriptions and quantifiable data that offer insight into changes in the patient’s condition.
  • Subjectivity in Objective Data: While the Subjective section captures the patient’s personal reports, the Objective data should remain factual and unbiased. Resist the inclination to let patient expressions influence objective observations.
  • Inconsistency in Details: Failing to consistently document the same types of information can lead to gaps in data, making it harder to track progress or changes accurately.
  • Neglecting the Plan: Each note should end with a clearly outlined Plan that includes any changes based on the day’s findings. This section should guide the next steps and not just repeat previous plans without considering current assessments.

Effective SOAP notes are indispensable in rehab therapy. They not only provide a structured way to document care but also ensure that all healthcare providers are informed and aligned on the patient’s treatment plan.

By following these best practices and avoiding common pitfalls, therapists can enhance the quality of their documentation, thereby improving patient outcomes and ensuring compliance with healthcare standards.

Simplify SOAP Notes Using Tech-Based Tools

Electronic health records (EHR) solutions are reshaping how SOAP notes are used in rehab therapy. These systems facilitate quick data entry, immediate access to patient records, and the integration of various data sources. In doing so, EHRs enable rehab therapists to improve:

  • Efficiency and Accessibility: Digital SOAP notes can be quickly accessed by any member of a healthcare team from virtually any location. This accessibility is crucial for multidisciplinary teams working in different locations or for therapists who need to review patient histories quickly.
  • Data Integration: EHR systems allow for the integration of SOAP notes with other patient data, such as diagnostic tests and previous medical records. This holistic view supports more informed decision-making and personalized patient care.
  • Security and Compliance: Digital systems help ensure that SOAP notes and a patient’s full medical history are secure and compliant with health information privacy regulations, such as HIPAA in the U.S. They also feature built-in tools to audit and manage records efficiently.

Looking ahead, the future of SOAP notes in rehab therapy is likely to be shaped by advancements in artificial intelligence and machine learning. These technologies promise to further enhance the efficiency and effectiveness of SOAP notes.

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