Whether it is in the form of mental or physical therapy, there is no denying that you will also encounter notes that you need on a daily if not weekly or monthly basis. The SOAP notes that you write are not only beneficial to your work, but they are also very useful when it comes to looking for the right information or details and updates on your patients’ overall status. When people do hear SOAP notes, they often associate them with nurses, but the truth is that even therapists use these tools in their jobs. What exactly is a physical therapy SOAP note? To get the answers you are looking for, let’s take a look at the examples of a physical therapy SOAP note. See FREE 28+ Note Templates for other examples of note templates.
What Is a SOAP Note? We often hear nurse and psychiatrist SOAP notes, but more often than not, do we hear physical therapy SOAP notes? It is not as common as the ones above, but a physical therapy SOAP note is a type of SOAP note, like the ones mentioned above. A physical therapy SOAP note is a specific type of SOAP note whose basis is on the patient of physical therapy. Only this kind of SOAP note focuses on the physical therapy of a patient. The basis of this SOAP note is the history of the patient with the physical therapist, the reason for attending physical therapy, and the progress of the patient. The SOAP note has to also follow the format of a general SOAP note, the format being subjective, objective, assessment, and plan. Check FREE 19+ SOAP Note Examples for more.
Nurses have their own ways of writing their SOAP notes, and so do physical therapists. These two medical professionals may use the same tool, but the way they fill it out or make it may differ in some ways. For example, a physical therapy SOAP note may add in the equipment they use, while nurses do not have to. With that being said, here are some steps on how to make a physical therapy SOAP note. See How Do You Write a SOAP Note.
In writing the first things in a physical therapy SOAP note, you must at least be subjective to what you are going to be stating. But it does not mean that personal opinions are the things you will be adding. Rather, what you should be adding is the professional opinion you have as a physical therapist and how you believe your patient is handling the physical therapy. See 6+ Therapy SOAP Note Examples.
Assess, analyze and evaluate the status of the patient. When you make your SOAP note, this is the heart of the entire note. You must be aware of how you make the assessment and the evaluation as this is based mainly on the information you have on the patient and the progress or status as well. In order to administer the proper treatment, you must also administer the proper assessment and evaluation in your SOAP note. See 27+ Treatment Plan Examples in Google Docs | MS Word | Pages | PDF.
What is important in a SOAP note is the fact that it always has to be clearly written. The jargon that is used should be something that even your patient can understand. Be concise with what you are explaining and be sure to explain it properly in the SOAP note as well.
Lastly, check on the entire SOAP note. Make sure that you have not missed any information regarding your patient’s status or health as it is important to have to make everything complete.
A physical therapy SOAP note is a specific type of SOAP note whose basis is on the patient of physical therapy. Only this kind of SOAP note focuses on the physical therapy of a patient. The basis of this SOAP note is the history of the patient with the physical therapist, the reason for attending physical therapy, and the progress of the patient.
SOAP notes help in summarizing important information and details. In order to get every information in the right place and without having to go through a lot of documents, the SOAP note is the best tool to make.
The word SOAP stands for subjective, objective, assessment, and plan, all of which cover the general SOAP note.
It goes without saying, when it comes to filling out details about the notes you keep, there is only one tool that stands out for those working in the medical fields: a SOAP note. See 10+ Best Medical SOAP Note Examples.