Unit 10: Documenting Treatment and Discharge Flashcards
The treatment note is documented using the…
SOAP note format.
SOAP stands for…
Subjective, Objective, Assessment, and Plan.
-This is a typical format for treatment note writing, but there are other formats you may be exposed to at some point in your career.
Discharge Note
- Similar to a treatment note, but instead of recording plans for the next session it contains:
- Information about the achievement of goals during the therapeutic process overall
- Plans for where the client will go next (with recommendations for services or equipment
- An explanation of their performance now compared to their last evaluation.
SOAP notes are a key component of…
- Communicating with third-party payers
- Other practitioners
- Cients about their response to intervention and their potential for progress.
A good SOAP note can make the difference between…
- Continued coverage and discharge.
- You are responsible for making sure your clinical skills shine through and that you are using best practices to engage with the client and work toward achieving goals.
The SOAP note format is based in the…
Problem Oriented Medical Record or POMR, and it’s a format that’s client-centered and focused on problems and progress.
-This is what we want to be sure that we focus on, in our documentation
Using the SOAP Format…
- Standardizes documentation and it offers an outline for learning.
- Once you’ve learned the SOAP note format, you will know all the component parts that should be in documentation.
- If a site uses a different format, you’ll be able to adjust to that.
SOAP note format can be used to document…
- Evaluation, intervention, and discharge.
- So, there are a little bit different things that go into each section when you’re documenting evaluation, or discharge, because, often, at discharge, you’re measuring and documenting outcomes as well. But, intervention is probably that because you’re writing the most notes typically in intervention.
Subjective (S)
- Offers the clients perspective of the session
- Should be relevant to treatment or goals
- Includes info directly from the patient (what they said)
- Should be data that can be verified or measured such as: complaints of pain or fatigue/feeling, attitudes, concerns, goals, plans
- Use direct quotes or paraphrase what the client said
- In practice, you will elicit these comments by asking questions
Caregiver Input (subjective)
Particularly relevant with populations like children, with people who are with a caregiver quite frequently, and rely on that caregiver for a lot of day-to-day stuff.
- Sometimes it’s not so relevant to have the caregiver, who maybe isn’t with the person very often, they’re just the one who brought them to treatment. What they say may not be relevant. So, just keep that in mind when deciding what should go in this section.
- If unable to speak, include nonverbal communication or caregiver input
Objective (O)
-Measurable, quanifiable, observable data
-Offers a picture of the session (organized chronoloigicallt or categorically)
-Begin with a statement about length, setting (be specific), and purpose of treatment session
Be sure the data describes need for therapy:
-Explain clients deficits in client factors, performance skills, occupational performance
-Incliude assiust levels, type of assistance, and reason for assistance
-No assessment- just observable facts
Assessment (A)
- Therapists analysis or appraisal of client progress, limitations benefits from OT
- Use clinical reasoning to interpret data presented in “S” and “O”
- 3 P’s: Problems, Progressm Rehab Potential
- Also include incosistencies, emotional components, changes
- Justify continued OT services
Plan (P)
Anticipated frequency, duration, and purpose of continued services
- Use clinical reasoning to determine
- Frequenxy and duration may be determined by setting, funding, or MD order
- Specific interventions to be used and priorities regarding strategies (also determined by current setting)
- Must relate to “O” and “A”
- Should flow from what you included in your assessment
General Guidlines for SOAP Notes
- Be sure info is included only in correct area
- Info should build on itself (no new info in “A” or “P” that was not described in “S” and/or “O”
- Ensure that the note is complete and organized
- Writing should be clear and concise
- No grammar, spelling, or punctuation errors
- Professional Presentation: Typed or legible handwriting (black ink), neat
- Sign using credentials, date, print name
- Use checklist and guidlines
When asked, client indicated that she has not been preparing her own meals since she has been home, and would like to makie a sandwich today. When she was unable to open the mustard jar with one hand, she put it aside and said she didnt like mustard much anyway
(Example SOAP Note)
S
