Do you feel confident writing a SOAP note and providing accurate documentation?
I think this is something we all worry about!
We have so many pressures to get all of our patients seen and get all of our SOAP notes done in a timely fashion. Since documentation time is not reimbursable, we have to also be efficient, all while actually producing therapy notes that are defensible and complete.
I am going to be sharing what goes into a SOAP note, and then feel free to dig into this a little deeper by listening to each of the episodes of the Seniors Flourish Podcast with an amazing series with Dee and Cindy by Kornetti and Krafft Health Solutions. They go through each area of the SOAP note (Subjective, Objective, Assessment, Plan) and give detailed tips and things to think about when crafting the perfect OT note - plus they make learning about documentation (dare I say it?!) entertaining!
They also present an entire series through Medbridge and present a framework for defensible documentation that teaches you how to work "smarter, not harder" when it comes to SOAP notes and documentation. Even though the course says it is geared toward home health OT and PT practitioners, I have found this information to be completely applicable to other settings.
In this post, I will also be sharing basic tips, an occupational therapy SOAP note example and template, and include key phrases for billing and reimbursement at the end. This is post is an example of the content that is in the Learning Lab membership - helping you to have the resources you need to feel confident and successful as an OT practitioner and student!
It's a lot of good stuff, so let's dig in!
How to Write a SOAP Note
The Soap Note Template
The basic format for a SOAP note is as follows:
Many times this is not laid out in this manner through our documentation systems and we get a big 'ol blank box to write our daily note in. To make this easier and to make sure I am hitting everything that needs to be covered in my note, I will put each letter down the left side of the open paragraph area and write it as a SOAP note format anyway.
Think of writing a SOAP note as writing a story.
What if someone was to step into your role for the day (and that happens all the time, right?) and needed to get a good understanding of what is going on with the patient, what you currently are working on, how do you feel about their progress and then what are you hoping to do next visit or in the near future? You would probably write your note a little differently than if you were treating that patient yourself tomorrow, right?
Or consider someone in Utilization Review reading your note and deciding if your treatment sessions are skilled or medically necessary?
Through listening to this podcast series myself, I have also learned that just because our patient is not making progress, does not mean that your skilled services will be denied! It is our job to paint a picture of what is going on with our patient, why they are or aren't progressing and lay out a plan for progressing the goals, adapting the goals or shifting direction in care.
This shows skill and involvement in care.
The Subjective portion sets the stage of your story!
* Ask yourself: What is the pertinent info that the patient states that potentially could affect OT intervention?
- patient questions about plan, treatment or outcomes
- reflections of progress or current problems
- current day's symptoms or complaints
- direct quotes (I use a lot of these!)
Ex: The patient states that she has not been able to use her wheelchair around her home due to her "hands hurting" and "I am not able to get a good grip."
Episode 1/5 of the documentation series: SUBJECTIVE
Ask yourself: What did you do to make the tx session skilled (not just what the patient did in the session - don't exclusively list out completed activities/interventions)?
- address how intervention is working toward goal
- any new interventions introduced?
- objective measures and observations
- how you graded the activity (Tips for Grading Tasks)
- specific treatment given using skilled terminology
- purposeful activities
- occupation based
- OT Practice Framework does an amazing job providing the key words to use to justify services and demonstrate our expertise
- quantifiable information and compare to initial eval or previous sessions (give me some numbers - not just for evals and progress notes! 🙂
Episode 2/5 of the documentation series: OBJECTIVE
Ask yourself: What is the patient's current condition (today) and how does it affect the achievement of their goals? Am I on track with the goals, do I need to modify them or change direction of my treatment interventions?
- Is the patient making progress? why or why not
- What can we do about limited progress (try a new intervention? discuss with MD/family/healthcare team? cognitive factors? etc)
- What are the patient's barriers to progress and how can they be addressed?
- Social emotional impacts - motivation, participation, effort, etc
- Carryover of instruction by patient/staff/care partners
Episode 3/5 of the documentation series: ASSESSMENT
Ask yourself: Why does this patient need continued skilled occupational therapy treatment and are there any changes that need to be made to the plan of care?
- Be specific on modifications to treatment plan (or direction of treatment plan)
- Notifications, communications or referrals made to RN/MD/PT/SLP, etc that need to be addressed
- Recommendations/plan for changes of frequency, duration, etc and why
- Future trials (including equipment, strategies, etc) that you would like to address
Episode 4/5 of the documentation series: PLAN
Documentation Tips and Answering Your Questions
In this last episode of the series, some of you were able to join us live and ask all sorts of questions about documentation, SOAP notes, assessment and regulations. It is a good overview and really shows the expertise Kornetti and Krafft bring to the documentation table.
Episode 5/5 of the documentation series: YOUR Burning SOAP Note Questions Answered - Live
SOAP Note Example:
S: The patient states that she has not been able to use her wheelchair around her home due to her "hands hurting" and "I am not able to get a good grip."
O: The OT assessed the w/c and modified it by building up the rims with self adherent tape. Instructed in how to propel w/c over carpet and thresholds of home safely. The pt demonstrated ability to self propel 100' with min VC while reporting 0/10 hand pain after adaptation.
A: After adaptation and instruction, pt improved in self propulsion and increased independence in functional mobility within her home environment. She is motivated to return to being independent in her home and is very receptive to instruction.
P: Pt would benefit from continued skilled OT intervention to educate the pt on utilizing w/c down ramp to access her living area. Will acquire ultra grip built up rim covers for trial at next visit to see if that is a better long term solution vs the tape.
Looking for more documentation information?
Head over to: Documentation Domination for OT Practitioners Working with Older Adults or check out the Learning Lab - it has more documentation tips and goal writing examples, as well as OT treatment ideas, education videos, clinical resources, patient handouts, assessments and support!