These highly detailed notes are used to document patient progress throughout the course of their treatment. While there are many ways a physical therapist can document patient progress, physical therapy SOAP notes are the most comprehensive and structured way to go. Detailed patient notes are important as they help keep communication flowing seamlessly between providers. According to Physiopedia.
7 Essentials to Writing Effective Pediatric OT SOAP Notes
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T herapists must use SOAP notes to monitor and document patient progress, log services, and communicate patient information to other professionals. Th is SOAP notes overview and actionable pointers will help you write notes in a clear and efficient manner. SOAP notes were first introduced by Dr. Lawrence Weed a bout 50 years ago ; their creation revolutionized the medical industry as the first proper method of documentation. The exercise varies by field and allows plenty of room for customization, but t here are four universal components. Subjective — The subjective section is for patient input. These are statements provided by the patient about their symptoms and current condition.
Both occupational therapy and physical therapy soap notes should have the same basic format whether you are writing an evaluation, a daily note , a progress note or a discharge note. He continues to manage his symptoms with ibuprofen daily and reports improved ability to reach to low cabinets in the kitchen. Descending stairs have been very difficult due to LE weakness.
Clinical documentation and reporting has never been quicker, easier or more comprehensive. From evaluations and daily SOAP notes to audit-ready records, ClinicSource therapy documentation software empowers you to be a more productive and thorough provider. Intuitive platform streamlines documentation. Plus, you can add any new discipline you want. Therapist-developed Treatment Log simplifies and streamlines session recording.