Chapter 7: Introduction to Note Writing

Introduction

Therapists and therapist assistants document patient care using one of two note formats. One of the formats they use is called a SOAP Note. Another format is the Patient Management Note.

The SOAP and Patient/Client Management formats for writing notes are not the only ones used in therapy clinics. It is rare for a healthcare professional not to encounter one of these two documentation formats, or a variation, during his or her career. This textbook will teach you how to write notes in both the Patient/Client Management Note format and the SOAP Note format. Both formats can be adapted to meet the requirements and needs of any facility.

The Patient/Client Management Note

The Patient/Client Management model described in the Guide to Physical Therapist Practice¹ contains the following components:

• History

• Systems Review

• Tests and Measures

• Evaluation

• Diagnosis

• Prognosis

• Plan of Care

The American Physical Therapy Association first published The Guide to Physical Therapist Practice in 1997.¹ After reading the framework for and description of practice published in the Guide to Physical Therapist Practice, physical therapists began to discuss the implications for documentation. Therapists attempted to construct paper documentation forms and computerized documentation formats that were consistent with the framework of practice outlined in the Guide.

The second edition of the Guide, published in 2003, included a Documentation Template for initial inpatient and outpatient settings.² Some facilities have adapted the Documentation Template with the Patient/Client Management Note in mind. The result is a documentation format that contains all the elements of the Patient/Client Management model described in the Guide.

The SOAP Note

SOAP is an acronym for the four major sections the patient/client note. The SOAP Note is divided as follows:

• S stands for Subjective.

• O stands for Objective.

• A stands for Assessment.

• P stands for Plan.

In most facilities, a fifth section, the Problem, is included before the S portion of the note.³ The Problem section includes information specific to the reason the patient is coming to therapy.

The SOAP Note was introduced by Dr. Lawrence Weed in the early 1970s as part of a system of organizing the medical record, called the problem-oriented medical record (POMR).^3-10 At the time, a health record was called a medical record. The POMR had one list of patient problems in the front of the medical record, and each healthcare practitioner wrote a separate SOAP Note to address each of the patient's problems. Many facilities never used the POMR but instead adopted a different organizational format for the health record. Other facilities used an adapted POMR format. In any case, one contribution that clearly came from the POMR was the widespread use of the SOAP Note.

Professionals in many ...