Documentation Formats

Question 1

Narrative Note Writing

Answer 1

• descriptive encounter with patient written in paragraph format
• type of encounter: sequence of events/unusual incidents; conversations with HCPs, Pts, family members
• pros: good for telephone conversations, detailed, comprehension, timeline aspect is good, liability purposes (litigation), paints vivid picture, helpful in detailing conversation, pediatric (read by laymen), puts jargon in context
• con: not super efficient, less comprehensive, lack of organization, may omit items, variability

Question 2

SOAP Notes

Answer 2

• provides structure to medical notes
• S: what patient tells you
• O: anything that can be measured
• A: interpretation
• P: what you’re going to do about it
• S and O make up examination
• A and P make up evaluation
• PR: section is medical diagnosis, referral information, and medical record findings that precedes SOAP note in initial patient encounter

Question 3

Subjective

Answer 3

• what is reported by patient/family-symptoms, complaints, contextual factors, personal goals, relevant medical history
• not observed by therapist
• ex: pain, changes, functional limitations, participation status
• incorporating ICF model language into this model is a MUST: historically S heading associated with pain
• comparison with patient client management model: heading-examination, subheading-history

Question 4

Objective

Answer 4

• what can be measured: systems review, interventions provided, relevant tests and measures
• examples that are ICF-based
• comparison with ICF model: objective data-systems review, tests and measures

Question 5

Assessment

Answer 5

-interpretation of findings: relationship between impairments and function, problem list, rehab potential, PT diagnosis, prognosis, and dx goals, medical necessity
-initial documentation: relationship between impairments and activity limitations/participation restrictions
-interim: progress toward goals, summary of changes (daily note, reevaluation/reassessment)
=comparison to P/C managment: evaluation

Question 6

Plan

Answer 6

• specific plan for patient management of PT-related problems
• initial: medical necessity, referral justification, plan for patient/family education, plan for new intervention to be added, frequency, duration, amount of treatment
• interim: plan for reassessment, change in POC

Question 7

SOAP Pitfalls: Subjective

Answer 7

• too focused on pain, not enough emphasis on function

- solution: use activity limitations, participation restrictions and contextual factors as basis for taking history

Question 8

SOAP Pitfalls: Objective

Answer 8

• written in terms of impairments only

- solution: find outcome measures that objectively describe participation

Question 9

SOAP Pitfalls: Assessment

Answer 9

• written in term sof how patient tolerated treatment

- solution: describe relationship between pts impairments and improved function, with reference to objective data

Question 10

SOAP Pitfalls: Plan

Answer 10

• to general: “continue per plan”
• solution: what are you going to add, delete from POC? discuss patient education plans moving forward and what you plan to reassess next session