Physical Therapy Documentation and Soap Note Examples
By Ed Lamb, Contributor
Physical therapy documentation examples abound online. A question many of the therapists who use MedTravelers' services often ask is how they can choose the best SOAP note examples for their own practice. Detailed SOAP notes matter because creating and sharing complete and easy-to-understand documentation makes a world of difference in terms of receiving on-time payment and guiding patients toward treatment goals.
Remember That Each Physical Therapy Patient Encounter Requires Documentation
Before reviewing examples of physical therapy documentation, reflect on the need to document each patient assessment and intervention, every treatment plan, and all clinical observations.
Your files on each patient should include records of consent to new tests and therapies, the dates of (and reasons for) every home visit or office appointment, the patient’s medical history, releases for health information checks and disclosures, procedures, clinical judgments, responses to treatments, and the patient’s feedback. Third-party payers and boards will want these details, and every piece of information will help you take better care of your patients.
Keep Your Physical Therapy Documentation Clean With SOAP Notes
As one more general guideline for estimating the value of an example of physical therapy documentation, ask yourself if the template follows the SOAP note format.
You probably remember that the acronym stands for “subjective, objective, assessment and plan.” A form for documenting your patient encounters should allow you to record the following details:
- - The patient’s subjective statements on his or her condition and thoughts on the value of treatments
- - Your objective observations of the patient’s condition and measurable responses to interventions
- - Your assessment of what both the subjective and objective information indicate
- -The plan for ongoing treatment
Defensible Documentation for Physical Therapy
The American Physical Therapy Association (APTA) offers this checklist for defensible documentation of physical therapy assessments and interventions. One of the most useful features of the SOAP note guidelines for PTs are the top-10 tips for defensibility:
- 1. Limit use of abbreviations
- 2. Date and sign all entries
- 3. Document legibly
- 4. Report functional progress toward goals regularly
- 5. Document at the time of the visit when possible
- 6. Clearly identify note types (e.g., progress reports, daily notes)
- 7. Include all related communications
- 8. Include missed/ canceled visits
- 9. Demonstrate skilled care and medical necessity
- 10. Demonstrate discharge planning throughout the episode of care
Document Medical Necessity and Services
If you want a more detailed example of what to include in your physical therapy documentation, consult this memo from Blue Cross and Blue Shield of Kansas. The CPT codes are out of date, but the guidance on what to record, ranging from the patient’s name on each page to flow charts of progressive interventions, remains unimpeachable.
The insurer advises that complete physical therapy documentation should allow “a peer reviewer…to discern the medical necessity without knowing the patient as well as you do.”
Document Patient/Client Management
When you need an even more in-depth example of how to document physical therapy patient management, you can benefit from returning to the APTA website and reading through the association’s guidelines. The specific lists of what to record when taking a patient’s history, conducting reviews of metabolic systems and performing functional tests can prove particularly valuable when meeting with a new client for the first time.
Medicare Part B Documentation
Two resources for documenting physical therapy for Medicare patients recommend themselves based on their authors and their titles. The first is hosted on the Centers for Medicare and Medicaid Services (CMS) website and bears the self-explanatory name “11 Part B Billing Scenarios for PTs and OTs.”
Visiting the CMS Therapy Services webpage at least once a year is a good idea because CPT codes and billing procedures are subject to change.
A broader guide to Medicare Part B physical therapy documentation appears on the APTA site. This outlines the types of information to include under the four main categories of evaluation and plan of care, physician or nonphysician practitioner’s certification of care, progress reports, and treatment notes.
Med Travelers loves to keep our clinicians updated on the latest developments in things such as SOAP notes and documentation tactics for physical therapists. We pride ourselves on helping clinicians achieve their goals and can help PTs who are interested in travel jobs make the transition. Begin by searching PT travel jobs and then complete your application from the link below.
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