9-30a Documentation

Question 1

Why is documentation important?

Answer 1

track progress
reimbursement
insurance purposes/satisfy third-party payers
if it wasn’t documented it didn’t happen
important communication tool
communicate abilities and unique body of knowledge
legal situations

Question 2

Who reads your SOAP notes?

Answer 2

PTS: hand-off, inform POC
Managers/Administrators: audits
Patients/Family members: keep it professional
Providers outside Institution: make it easy to understand
Members of Medical team (therapists, nurses, social workers/case managers for assist w/ next level of care

Question 3

What are some essential broad requirements for SOAP notes?

Answer 3

document every encounter
document no-shows
comply with regulations
HIPPA
chart errors (strikethrough/name/date)

Question 4

What are some specific requirements for SOAP notes?

Answer 4

Full name/ID #

date/full legal name/include designation

Question 5

Reasons for Payer Complaints

Answer 5

Legibility, Incomplete, No documentation, doesn't support billing (coding)
non-medically necessary info
no progress
repetitive notes
no clarification for intervention

Question 6

Use Skilled Service Language

Answer 6

Demonstrate specific expertise knowledge, clinical decision making, and PT abilities
words that reflect expertise

Question 7

Describe the Subjective portion of the SOAP note and decide upon an example

Answer 7

Things the patient tells you about:
Condition, previous response to treatment, things they see as improvement, or things they have difficulty with, complaints of pain (can be objective with standardized scale)

Include direct statement from pt and make sure it provides detail about the above

Make sure it informs the picture

Question 8

Describe the Objective portion of the SOAP note and decide upon an example

Answer 8

Facts, interventions, specifics, communication, instruction, modalities used, equipment used

Specific enough to be repeated by someone else

Ex.: Transfers: w/c <> mat with sliding board with min assist

Question 9

Describe the Assessment portion of the SOAP note and decide upon an example

Answer 9

○ Think about how all the pieces came together to produce a result
Req. skill and clinical decision making (documentation helps with clinical decision making)

Justification for need of skilled services

Medical necessity

ICF: how do these impairments translate to functional activities and what is the impact on participation

Question 10

Describe the Plan portion of the SOAP note and decide upon an example

Answer 10

○ Specific plan for pt’s treatment schedule/exercises/consult/when re-evaluation and discharge will happen
○ Linked towards written/will-be-written goals