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Introduction

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When a therapist sees a patient for the first time, the therapist performs a comprehensive examination of the patient. The information gathered in the examination, in combination with clinical judgment, allows the therapist to determine the diagnosis, prognosis, and plan of care for the patient,1 so documenting the results of the examination is a critical component of documenting patient care.

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As mentioned in Chapter 7, the examination is documented somewhat differently in Patient/Client Management Note and SOAP Note formats. The Patient/Client Management Note organizes the information by the patient management processes that occur in patient care, or the nature of the data. The SOAP Note organizes the information according to the sources of the information.

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Part III discusses how to document the information gathered from interviewing the patient and the results of the hands-on part of the patient examination. The History, Systems Review, and Tests and Measures sections of the Patient/Client Management Note are presented in Chapters 11 and 12. Then the Problem, Subjective, and Objective sections of the SOAP Note are presented in Chapters 13 through 15. Worksheets at the end of the chapters allow you to practice and gain confidence in documenting these sections of the two note formats. Worksheets for the Patient/Client Management Note discuss one group of case study patients throughout this textbook. Worksheets for the SOAP Note discuss a separate group of case study patients throughout this textbook.

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It should be noted that the American Physical Therapy Association (APTA) is encouraging the use of note formats that more closely mirror practice,2 as described in the Guide to Physical Therapist Practice.1 The Patient/Client Management Note format closely aligns to the format encouraged by the APTA. However, the specific note format that a therapist uses may be determined by the employer, especially at larger institutions. In such instances, therapists who have been using the SOAP Note format may find their only option is to change the SOAP Note format to more closely mirror practice as described in the Guide to Physical Therapist Practice. This text offers both formats so that therapists can use a format that will more closely align with the patient management process described in the Guide to Physical Therapist Practice and the documentation encountered in their particular clinical environment.

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