Among the different systems that physical therapists use to track patient’s progress, SOAP is one of the most comprehensive methods. It enables you to keep clear, accurate, and concise records regarding every patient encounter. This is especially important for practices with multiple therapists, who may take turns treating the same patient. Besides keeping you on top of patient progress, SOAP notes can be your defense in third-party audits.
SOAP has existed for several decades, but some practitioners still don’t use them properly. We will explain everything you need to know about creating SOAP notes in your physical therapy practice, and how they can help you avoid an audit.
An Overview of Writing SOAP Notes
There isn’t a one-shoe-fits-all procedure for writing a SOAP note. However, your SOAP notes would be meaningless if they lack the information a third-party would be looking for about your interaction with a patient.
The four pillars of SOAP describe the kind of information you should utilize to develop useful SOAP notes. Here is what you to include:
Subjective Information – What the Patient Says
A SOAP note should always begin with what a patient says about their condition, which constitutes the chief complaint. The details will differ with patients and the stage for which you’ll be writing. Collect all the information you can get without making assertions or interpretations including:
- The symptoms’ onset
- Palliating or provoking factors
- Quality of the symptoms
- The affected region of the body
- The severity of the symptoms
- Time course of the symptoms
Objective Observation and Treatment Therapies
The second part of a SOAP note entails what a therapist collects during the patient encounter. Recording your unbiased findings and treatment interventions is essential. Functional tests and measurements will be recorded as objective information related to the specific condition being treated.
Assessment: Therapist’s Assessment Analysis
The assessment will summarize the patient’s age, medical history, diagnosis, and clinical stability in a few sentences. Report a differential diagnosis for the possible diseases or conditions associated with the patient’s symptoms, and any notes regarding the patient’s progress.
With the frequency of physical therapy being more than a normal doctor’s visit, at each appointment a therapist will document age, medical history and diagnosis that could affect treatment, how the patient tolerated it, or how treatment may be hindered.
Report Your Treatment Plan
If met with an audit, your detailed notes outlining the post-session plan for care can be the difference in passing or failing. While the patient’s state will dictate the kind of treatment they require, plans should include detailed notes regarding:
- Treatment goals
- Follow-up appointments
- Referral other facilities or specialists
- Recommended additional tests
- Home exercise programs (HEP)
Prevent Audits with SOAP Notes
Modern healthcare systems have embraced value-based care models. In a bid to cut costs, third-party payers, including Medicare, have heightened medical audit reviews. The aim is to prevent care providers from exploiting the system by overcharging patients. In 2016 alone, recovery audit contractors (RACs) recovered a whopping $214 million from health practices and returned it to Medicare.
SOAP Notes and EMR Integration
SOAP notes are vital for top-notch documentation and reporting to prepare your clinic for an audit. The correct electronic medical records (EMR) system can incorporate all the changes a patient undergoes during the treatment period. Such a tool can eliminate redundant data entries, leading to better efficiency. You can quickly view a patient’s medical history, goals, and intervention.
A2C Flow Sheets for SOAP notes, Audits and Compliance
A2C Medical encourages our clients to use our flow sheet to ensure their practice is in compliance with mandates and laws. For example, when using our flow sheet, there is no way to charge for a service that wasn’t documented. In fact, we have had several customers who have passed audits with flying colors all due to their detailed flow sheet notes.
A2C Medical’s flow sheet forces compliance with:
- Objective text that is automatically populated based on the functions (treatments) that are performed
- Calculated units based on direct contact time
- Charges only applied after the note is signed by the therapist
- Changes only made to items they have marked off in the flow sheet
Perfect SOAP Notes for Audit Preparation
Since SOAP notes require so much detail, their benefits to the audit process are boundless. Here are a few ways writing impeccable SOAP notes pays off for physical therapists going through an audit:
Evidence of Patient Interaction
As a therapist, you might require to prove that a patient visited your clinic and what transpired during the session. SOAP notes are quite specific about the date, time, location, professional assessments, treatment therapies, and much more. They can serve as proof of patient interaction.
Records for Future Reference
Creating exhaustive therapy SOAP notes is a surefire way of collecting data about patients and various interventions. The information provides reference points in a patient’s treatment journey, enabling you and other care providers to treat patients more accurately.
Extra Tip: With detailed treatment notes for every patient who visits your clinic, you can also build a resourceful library. You can replicate the solutions that work for specific conditions and find alternatives for ineffective interventions.
Seamless Information Sharing
Many physical therapists accept SOAP as the standard way to keep medical records and share them with their peers. The notes are particularly important when serving a patient who seeks treatment from different specialists. Your patients get the documentation other caregivers need to participate in the healing process, especially in complicated cases.
Reporting Software for Therapists
Are you a physical, occupational, or speech therapist looking for a convenient way to cover all your clinic’s operations? Utilize the comprehensive reporting system by A2C Medical to generate flexible, custom reports. Having a summarized version of the right data at your fingertips will help you make informed decisions for your practice.
With executive reports, you will have a panoramic view of your clinic’s productivity. View the patients you have served as well as your charges and collections for the day. You can also tell who misses or cancels their appointments at a glance.
Stay Compliant with A2C Medical
A2C Medical offers a set of standard clinical forms for physical and occupational therapists to ease your daily tasks. You can customize them to your needs or create new ones from scratch. With a digital signature feature, only authorized persons can fill or modify forms. Read more about our custom solutions tailored to your practice’s needs.