Physical therapy notes are documents used by physical therapists in the form of soap notes which include Subjective, Objective, Assessment and Plan. These notes record information about the progress of the patient and a professional medical transcription company can deliver accurate transcripts for hospitals, outpatient clinics, group practices and individual physicians. Converting physical therapy dictations or notes into proper and accurate medical records is vital to ensure appropriate patient care, accurate medical claim submission, and efficient administration of hospitals. A good transcription service understands the working environment of the physical therapist and their need to maintain accurate medical records.
What Do You Mean by SOAP notes?
Physical therapy SOAP notes contain details about the condition of the patient, and the treatment to be provided. It should also include the frequency, duration and the equipment used for treatment. The progress of the patient and the response towards the treatment may also be mentioned in the physical therapy notes. With all this information, it provides an outline of the course of treatment provided that are later transcribed. Here are some tips to write SOAP notes for physical therapy.
SOAP refers to Subjective, Objective, Assessment and Plan. According to the American Physical Therapy Association the Physical Therapist SOAP notes should include:
- Self-report of the patient
- Information about the specific intervention provided
- Equipment used
- Changes in patient health
- Any drastic reactions or changes
- Progress
- Communication with other physicians or other healthcare professionals
Let us consider the 4 Parts of SOAP notes
- Subjective: This part includes every detail about what the patient has to say about his/her health condition. It provides insights about how the patient feels about his/her progress, whether they are able to function well and whether their quality of life has improved. It also includes the patient’s description of pain, dizziness or any other discomfort. Sometimes patients may not have any opinion about their treatment. So when required, it is useful to take subjective opinion from the family members too.
- Objective: This includes all the pertinent measurements like vital signs, range of motion, muscle setting measurements and so on. The therapist should also include frequency, duration and the equipment used. Although this document does not have much legal value, all details should be accurate as it determines the treatment.
- Assessment: It includes all the impressions from the physician regarding the patient’s health condition. In this document, the physicians must explain how they have decided about the treatment, and how they intend to work with the patient. This is the document where therapists record their professional take on each session, therefore it holds legal value.
- Plan: This is the final step which mentions all the details about what treatment plan is set for the patient. It also has the development of the patient’s treatment plan.
Advantages of Writing SOAP Notes
- Act as Proof: Accurate SOAP notes serve as proof of interaction between the doctor and the patient. It covers all basic details like date, time, and location that are relevant. It also includes different types of treatment. The physical therapist may use these SOAP notes if they work with patients who may need extra level of documentation for legal purposes.
- Useful for Future Reference: SOAP is a detailed report of treatment that allows medical professionals to build their own mini-research library. SOAP notes help to collect data that can be used as reference throughout a patient’s journey.
- Information can be Shared among Peers: SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. SOAP notes play a huge role in ensuring clear communication regarding the patient across all healthcare team members.
A good transcription service provides accurate medical records for conditions associated with back pain, sports injury, cerebral palsy, frozen shoulder, osteoarthritis of the foot, strains and sprains. An experienced and reputable provider of medical transcription services can be of great support in preparing SOAP notes for physical therapists, ensuring confidentiality of patient data while also maintaining security policies.
