Initial Visit SOAP Documentation PDF

Initial Visit SOAP Documentation Objective Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the components that comprise the objective portion of a SO...

Initial Visit SOAP Documentation Objective Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the components that comprise the objective portion of a SOAP note during an initial physical therapy visit 2. Recognize the process of collecting and documenting patient information in the objective exam 3. Compile and categorize objective data from a patient scenario into a systematic and coherent objective section of a SOAP note Objective Data You Measure Systems Review Tests and Measures Observations Functional Activities Gait Analysis Objective Components not ROS Systems Review Quick Screen of Major Systems Cardiopulmonary Cardiopulmonary Integumentary Integumentary BP Edema Musculoskeletal HR caprefill Neuromuscular Systems Other Communication H Review Gast Reflexes Balance Affect Musculoskeletal Neuromuscular Cognition Learning Ro strength Transfers Systems Review Often a Systematic Process Quick Screening Exam Helps us determine if PT is needed Drives tests & measure selection Systems Review Cardiopulmonary HR: 86 bpm; RR: 14 bpm; BP: 126/80 mmHg Case Example Integumentary 6-inch incision at anterior R knee; appears to Format be healing well… Table Heading and Short Statements Musculoskeletal Ht: 5’4” Current; Wt: 180 lbs Specific or Generalized Posture: forward head and rounded Impaired shoulders Unimpaired Gross ROM: impaired with pain at R knee; all others unimpaired Gross Strength: weakness and pain with resistance to R knee flex and ext; all others unimpaired Systems Review Case Example Neuromuscular Gait: impaired Transfers: independent in sit to/from Format stand, but slow/guarded Table Balance: unimpaired Heading and Short Heel/Toe Walk: unimpaired Statements Squat: impaired due to R knee pain and ROM limitations Specific or Generalized Impaired Cognition/Affect Unimpaired A&O x 4, prefers verbal explanation and written handouts  Bike examp le verbal response from pt. intervention during considered an is Tests and Measures objective. But is suby. if thinking 26 Categories; Guide to PT Practice. in retrospect Aerobic Capacity ßà Work Life Some Overlap of Data Between Categories Examples Balance Gait Muscle Performance Posture Range of Motion Sensory Integrity  Gait Tests & Measures Patient demonstrates antalgic gait on R with Case Example shortened stance phase and wide base of support; independently; slower gait speed; 4 wheeled walker. Timed up and go test: 14 sec. Format Heading and Short Statements Observation Table Format ROM, MMT, MMT Left Right Current Comments (*= pain) Special Tests, etc. Measurements Knee Ext 5/5 3+/5* 3/10 NPRS reported Knee Flex 5/5 3+/5* 4/10 NPRS reported Hip Flex 5/5 4/5 No pain reported In Summary References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Initial Examination and Evaluation, accessed 23 February 2024, https://www.apta.org/your-practice/documentation/defensible- documentation/elements-within-the-patientclient-management-model/initial-examination Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. SOAP Note Documentation Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. List the four components of the SOAP note framework 2. Explain the purpose and significance of the SOAP note framework in physical therapy documentation 3. Outline the specific information that should be included in each section of a SOAP note What is SOAP Note? Subjective—Hear Me ROS Objective—See/Watch/Move Me Tests Assessment—Figure Me Out Interpret Plan—Help Me Interventionsa , Purpose of a SOAP Note 1. Communication Tool Among Healthcare Providers 2. Continuity of Care and Treatment Planning 3. Legal & Ethical Considerations Subjective 1. Gathering Patient Information History Chief Complaint Subjective Symptoms 2. Statement Sources Patient Caregiver Other Healthcare Providers Medical Records  Yat Rom measurements Objective Data Gathered 1. Observations 2. Tests and Measures 3. Clinical Findings 4. Levels of Assistance 5. Interventions Performed and Patient Response  tation Assessment Interpre Clinical Reasoning Analyze Subjective and Objective Data Formulate an Opinion Diagnosis Prognosis Treatment Rationale Clinical Impressions Justify Your Decision and Value “The Why” à ICF Model Plan Treatment Plan; Plan of Care Prognosis Interventions Goals Therapy Duration & Frequency Coordination Purposes Future Actions and Follow-Up Aims & Intention Therapist Recall Communication; PT/PTA Demonstrates Skill and Clinical Decision-Making Writing Tips 1. Clarity, Conciseness, and Objectivity 2. Avoid Jargon and Abbreviations 3. Documentation Best Practices Defensible Documentation SOAP Note Format Standardized Structure Types of Patient/Client Notes Initial Exam/Eval Note Daily/Treatment Note Progress/Re-Evaluation Note Follow-up Discharge Note Format Should Flow Related Information in Each Section Case Study of the Lower Extremity S: Patient reported she has a hard time getting out of her as kitchen chair at home; stated her legs feel weak O: Patient required 5 attempts to go sit to stand from standard chair; used 1 arm on arm rest and pulled up with the other arm on a counter; B knee and hip extension strength: 3+/5 MMT Kuna A: Patient’s impairments in lower extremity strength are leading to limitations in sit to stand transfers; this is causing thend decreased functional mobility and poses a safety risk strength- ening P: Will initiate transfer training using multiple surface heights; will work on increasing LE strength What is SOAP Note? Subjective—Hear Me Objective—See/Watch/Move Me Assessment—Figure Me Out Plan—Help Me References American Physical Therapy Association 2018, Documentation: Documentation of a Visit, accessed 23 February 2024, https://www.apta.org/your-practice/documentation/defensible- documentation/elements-within-the-patientclient-management-model/documentation-of-a- visit Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Initial Visit SOAP Documentation Plan Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the components included in the plan portion of a SOAP note during an initial physical therapy visit 2. Compose a clear and structured plan section of a SOAP note by integrating information gathered from a patient scenario Plan of Care Plan of Care Considerations Client Status Physical Cognitive Emotional Expected Progression Coordination PT Staff Health Care Providers Family/Caregivers Discharge Status/Location  allow flexibility to Plan of Care Components 1. Goals keep it general 2. Frequency & Duration E.g. Pt to be seen 2x/wk for 6 wks 3. Plans For: a. Interventions Tie to Impairments and Limitations Education Coordination and Communication b. Anticipated Discharge Plans Certain Settings Only E.g. DC to SNF or home with home health Case Example PLAN of CARE Frequency/Duration: Pt is to be seen in the clinic 2x/wk for 6 wks as indicated. Planned Interventions: Pt is to receive: palliative modalities to decrease pain/inflammation and reduce edema/effusion; manual therapy techniques to decrease pain and soft tissue tension and increase R knee ROM; gait training to improve mechanics and ability to negotiate stairs, and to decrease level of AD needed; progression in a therapeutic exercise regimen emphasizing R knee ROM, LE strengthening, and general conditioning. Education: Pt will be educated regarding examination findings, anticipated outcomes, and treatment options. She will also be instructed in an appropriate HEP. Communication/Coordination: Will coordinate POC with PTA who will follow up at next visit. References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Initial Examination and Evaluation, accessed 23 February 2024, https://www.apta.org/your- practice/documentation/defensible-documentation/elements-within-the-patientclient- management-model/initial-examination Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Goal Writing Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Recall the principles of setting SMART goals within an ABCDE(F) format 2. Describe the purpose and importance of patient-centered goals and how they influence the treatment plan 3. Develop SMART, ABCDE(F)-formatted, patient-centered goals aligned with assessment findings for a case study Goals “ The intended impact of functioning, with regards to z body functions and structures, activities and participation, as Goals a result of implementing the physical therapist plan of care —Guide to PT Practice  Problem List 1. Purpose of Goals Help PT Plan Clinical Decision Making Interventions to Meet the Needs of the Patient Interventions  Set ROM Goal 2. Purpose of Goals Set Objective Measures, Ensure Reassess ROM Progress with Treatment, and Reflect On Monitor Effectiveness of Intervention Interventions Effectiveness Adjust or Continue Interventions  Functional Underlying Limitation Impairments 3. Purpose of Goals Assist with Justifying the Medical Necessity Need for Skilled Intervention to 3rd Party Payers Skilled Need 4. Purpose of Goals Communicate Purpose and Expected Outcomes of Therapy to Other Health Care Providers  Ily Specific pt typias an destits. 1. Who…? What…? Where…? Why...? 5 wantRan i 2. Levels of Goals , goo Impairment Goals E.g. Increasing ROM, strength, etc. Patien Activity Goals E.g. Ambulation, transfers, other specific functional tasks Participation Goals E.g. Running a race, going to work/church, participating in other community events Measurable 1. How Much…? How Many…? 2. Concrete vs Abstract ! Increase R Shoulder Flexion ROM to 0-180º " Increase Shoulder ROM 3. Validated and Objective Measurements Achievable 1. How Can I….? Realistic…? 2. Achievement vs Process ! Will do ___ ; Will demonstrate ___ " Will work on ___; Will learn___ 3. Achievable vs Aspirational 1. Patient Status 1. Cognitive, Physical, etc Relevant 1. Does it Have Meaning…? 2. Collaborative a. Patient b. Family and/or Caregiver 3. Patient-Centered Goals Time-Based 1. By When…? 2. Predictive a. Reasonably Accurate b. Improves with Practice  Short Term Goals Pt to amb using a FWW 150’ over level ground Timeframe Categories in 2 weeks 1. Short Term Goals Achieved Early in Plan of Care Long Term Goals Building Blocks Pt to amb using a SPC 300’ over level ground in 4 weeks 2. Long Term Goals Achieved by the End of Plan of Care Plan of Care Pro PT Ini D isc tia gre ha l Ex ss V rge am isit ABCDE(F) Format: Actor 1. A à Actor Who is going to accomplish the goal? Patient Family and, or Caregiver 2. Examples Patient will…. Patient’s mother will… ABCDE(F) Format: Behavior 1. B à Behavior Activity to be accomplished Action verb after will Sometimes with associated direct object and, or phrase Only 1 Behavior per Goal 2. Examples Patient will WALK… Patient will INCREASE ROM… ABCDE(F) Format: Condition 1. C à Condition Circumstances or context in which “Behavior” is carried out Environment, Position, Assistive Devices, etc. May have multiple conditions 2. Examples Patient will walk with axillary crutches on level surfaces ABCDE(F) Format: Degree 1. D à Degree Quantified objective measure of the behavior Distance, time, ranges, reps, etc. Pain level, assistance level needed May have multiple degrees 2. Examples Pt will walk with axillary crutches on level surfaces 100 feet within 2 minutes Pt will be able to get in or out of bed without complaints of dizziness greater than 2/10 on 6/7 nights  Actor , behavior culition , Degree , ABCDE(F) Format: Expected Time Frame 1. E à Expected Time Frame Anticipate Goal Being Met Specific dates, weeks, visits 2. Examples Pt will walk with axillary crutches on level surfaces 100 feet within 2 minutes in 3 weeks Or by 12-31-20XX ABCDE(F) Format: Function 1. F à Function Impairment Based Goals Only Ties Impairment Outcome to a Functional Activity 2. Example Patient will increase R shoulder flexion AROM to 0-160º to be able to reach the top shelves of his cupboards by 12-31-20XX.  In Summary Patenterst Goals Tie Into the Examination and Evaluation Goals Need to Be SMART Activity and Participation > Impairment ABCDE(F) Format à Ensures Well Written Patient-Centered Goals References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Initial Examination and Evaluation, accessed 23 February 2024, https://www.apta.org/your- practice/documentation/defensible-documentation/elements-within-the- patientclient-management-model/initial-examination Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Patient Client Management Model Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT)  Learning Objectives 1. List the steps involved in the Patient Client Management Model from initial examination to outcomes 2. Explain the role of the Patient Client Management Model in guiding decision-making in physical therapy Patient Client Management Model ü History ü Systems Review ü Tests & Measures Referral Clinical Decision-Making Patient Client Management Model ! ! ! !  Observation ! & ! Assessment of Movement ! ! PT's "eyel  Lar back Chart pain Review History R/ODX Systems · muscle Strain Review · vertebralise Tests & · Herve impingem Measures ent Hypotheses  Chart Review Ep History Systems Review Tests & Measures Muscle Strain ! Vertebral Joint Issue Nerve Impingement Kidney Issues Hypotheses Cancer  Patient will be able to bend forward to pick Chart up their cat from the Review ground without limitations or History complaints of back pain in 4 weeks. Systems Review Tests & Measures Muscle Strain ! Impaired paraspinal muscle performance and localized inflammation associated with low back pain leading to limitations in activities of daily living, work, and household Hypotheses responsibilities  Chart Review History Systems Review Tests & Measures Hypotheses Reference APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org © All rights reserved. Applying SOAP Format to Patient Client Management Model Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objective 1. Match the steps of the Patient Client Management Model with the corresponding sections of a SOAP note Applying SOAP to Initial Visit Initial Visit Often Referred to as Initial Examination OR Initial Evaluation Based on PT Patient Client Management Model Applying SOAP to Initial Visit Subjective and Objective à Examination Assessment à Evaluation Plan à Plan of Care SOAP as Information Patient Client Patient Client “SOAP” Note Management Management Process Note History Systems Subjective & EXAMINATION Review Objective Tests & Measures Diagnosis Assessment EVALUATION Prognosis Interventions Expected Plan PLAN OF CARE Outcomes Anticipated Goals References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Treatment Visit SOAP Documentation Subjective & Objective Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the essential components of each section in a treatment visit SOAP note 2. Explain the methods for collecting and recording patient information in each section of a treatment visit SOAP note 3. Describe the elements required to create defensible documentation that reflects skilled care in physical therapy 4. Compile and structure follow-up information from a patient scenario into an organized SOAP note format Subjective Guidelines “This should reflect the patient’s, and at times S caregiver’s, self-report of status and response to previous treatment. Some tests and measures that are subjective may be included in the subjective portion of the SOAP note.” —APTA Subjective How Did You Feel After Last 1. Current Status Session? Symptom Status Functional Improvements Progress Towards Goals Remaining Impairments How Do You Feel Now? and Limitations 2. Relevant Events Response Post-Treatment and Between Sessions How Are You Doing with HEP Adherence X? New Injury or Event Medical Visits Additional Tests/Work-up How Are You Doing with HEP? Case Example S Patient states her neck felt much better after the last session. She reports her current pain as being 2/10 if she tries to turn her head to the right. Reports continued limitations backing up her car due to the limited neck motion and pain. Reports doing her home exercises daily which results in increased motion and reduced pain. Objective Guidelines This should reflect the physical therapist's objective findings made through observation of the individual, as O well as tests and measurements. The treatment provided to the individual and the response to treatment on that specific date also should be included in this category, but it should not be in place of objective data. —APTA Types of Information 1. Observations/Tests and Measures; Updated 2. Interventions Performed 3. Response to Treatment Formatting 1. Organization Categorical Chronological Hybrid 2. Type Flow Sheet Needs Skilled Narrative Used Alone à Standard Not Met Table Narrative Combination Observations, Tests and Measures Gait: Patient transitioned to SPC from FWW; amb 225’ over level ground; CGA; cueing for cane/step sequencing ROM 10/05/20XX 10/12/2XX 10/19/20XX Current Comments (*= pain) Measurements Flex: 0-165º* 0-172º* 0-175º No pain today for 1st time Abd: 0-170º* 0-173º* 0-180º No pain today for 1st time IR: 0-20º* 0-30º* 0-45º* Continued pain at end range ER: 0-70º 0-75º 0-82º Interventions Performed 1. Clarity and Accuracy E.g. ER; 3 x 10; Red 2. All Needed Parameters Sets, Reps, Rest and Recovery Resistance Machine Settings Patient Position Equipment Used 3. Client/Caregiver Education is an Intervention Interventions Performed Demonstrate “SKILL” Rationale for Intervention Measurable Changes Post-Tx Related to Patient Goals Cueing/Instruction Given Assistance Provided Safety Monitoring Needed Progression Over Time Interventions Performed Rationale Assistance Provided Added the following balance Sit ßà Stand; modA x 1 activities to address feelings of Supine ßà Sit EOB; minA x 1 to unsteadiness during gait manage L LE Cueing/Instruction Patient instructed to slide to Safety edge of chair and shift weight Donned gait belt and provided forward, "nose over toes" prior CGA to facilitate patient balance to attempting to stand from chair Correction/Feedback Progression Over Time Patient required verbal and tactile cueing to avoid scapular elevation and promote scapular retraction (progression10/01/2025 10/03/2025 over time) Treadmill 6’; 2.0 mph; 8’; 2.0 mph; during standing shoulder rows 0% grade 0% grade Interventions Performed Flow Sheet Format Intervention 10/01/20XX 10/03/20XX 10/08/20XX 10/10/20XX Recumbent Bike 5’; Level 3 5’; Level 3 8’; Level 4 10’; Level 5 Total Gym 3 x 10; Level 7 3 x 15; Level 7 3 x 10; Level 10 3 x 15; Level 10 20x each, B; 6” 20x each, B; 6” 20x each, B; 8” 20x each, B; 8” Fwd Step Ups step step step step Patellar: 5’ all Patellar: 5’ all Patellar: 5’, all Jt Mobilizations planes, Grade --- planes, Grade IV planes, Grade IV IV 5’ with PT 5’ with PT 8’ with PT 5’ with PT R Knee PROM provided provided provided provided overpressure overpressure overpressure overpressure 10/10/20XX Pt required verbal and tactile cueing to maintain R knee in alignment with ankle and hip during step ups; increased time on recumbent bike to promote endurance and facilitate patient’s goal to return to regular cycling Interventions Performed Table Format Intervention Description Manual Therapy Joint Mobilizations 12’; CPA grade III/IV at L4-L5 segments, patient prone Joint Manipulation 4’; S/L Lumbar Roll Grade V at L5 segment Neuro Re-ed DL Bridges w/ Marches 3 x 12 B with static glute isometric hold; cueing for midline engagement and glute activation; patient supine Hip Hinges w/ Dowel 20x; visual cueing with mirror required to improve performance; patient standing Therapeutic Exercise KB Deadlifts 3 x 15; 44 lbs KB, use of heavy band to facilitate hip hinge; verbal cueing for limiting knee flexion, patient standing Patient Education Emphasized the importance of performing written HEP daily and educated around the sequencing of the exercises Interventions Narrative Format Response to Treatment Data Only Not Your Opinion of It Current Session Only May Include Combination of: Patient Reported Response Observations with Interventions Changes in Measurements Before and After Intervention  Response to Treatment Before/After Measures Next to the Interventions Themselves Narrative at End In Summary Clarity = Duplication Skilled Care Progression Towards Goals  References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Documentation of a Visit, accessed 23 February 2024, https://www.apta.org/your-practice/documentation/defensible- documentation/elements-within-the-patientclient-management-model/documentation-of-a- visit Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Treatment Visit SOAP Documentation Assessment and Plan Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the essential components of each section in a treatment visit SOAP note 2. Explain the methods for collecting and recording patient information in each section of a treatment visit SOAP note 3. Describe the elements required to create defensible documentation that reflects skilled care in physical therapy 4. Compile and structure follow-up information from a patient scenario into an organized SOAP note format Assessment Guidelines This should reflect the PT's clinical decision making…, including their professional assessment of the patient's A progress, response to therapy, remaining impairments, activity limitations, participation restrictions, and possible precautions. This should not be documented as "treatment tolerated well. —APTA Types of Information 1. Overall Progression; or Lack Thereof a. Better, Worse, or Same Supported by Exam Data; S&O Relation to Goals Possible Theories Why 2. Assessment of Other Relevant Exam Data; S&O a. Not covered in previous statement 3. Assessment of Treatment Response 4. Justification for PT or Discharge Types of Information Prompts 1. How are they doing overall & specifically with regards to their goals? How can I support this? 2. What do additional statements or test and measure findings mean, that I didn’t specifically mention above? 3. How did they do with today’s treatment? 4. Why do they/don’t they need additional skilled PT? Case Example Pt continues to progress as noted with decreasing pain levels and improved Prompt exercise tolerance; increased in resistance 1. How are they doing overall level on Total Gym and time on and specifically with regards to their goals? How can I recumbent bike compared to last session. support this? She is also making progress toward her 2. What do additional statements ROM goal with increased range today, and or test and measure findings her ambulation goal as noted with lesser mean, that I didn’t specifically mention above? AD and improved amb quality. Case Example Prompt She continues to respond favorably 3. How did they do with today’s treatment? to Tx as noted with decreased pain post session. Patient tolerated treatment well by itself is NO GOOD Case Example Despite these gains, patient continues to have impairments with R knee pain with increased use and at end range ROM which Prompt can affect her ability to negotiate stairs; she 4. Why do they/don’t they need also continues to have limitations in gait. PT additional skilled PT? is indicated to continue to help her progress and overcome these impairments and limitations. Case Example A: Pt continues to progress as noted with decreasing pain levels and improved exercise tolerance (increased in resistance level on Total Gym and time on recumbent bike compared to last session). She is also making progress toward her ROM goal with increased range today, and her ambulation goal as noted with lesser AD and improved ambulation quality. She continues to respond favorably to Tx as noted /c decreased pain /p session. Despite these gains, patient continues to have impairments with R knee pain with increased use and at end range ROM which can affect her ability to negotiate stairs; she also continues to have limitations in gait. PT is indicated to continue to help her progress and overcome these impairments and limitations. Plan Guidelines The PT should provide specific information related to P the plan for future services including patient or client, or caregiver, education and any possible changes in the treatment program. Do not simply say ‘continue.’ —APTA Types of Information Follow-Up Plan Changes in Frequency and/or Duration Adjustments in Treatments Progressions Additions Discontinuations Plans for Future Measurement Discharge Visit à Final Plan E.g. “Discharge current bout of PT; patient to continue with HEP independently; patient will call to reschedule if symptoms return” Concluding the Visit Mutual Understanding Between Therapist and Client Regarding 1 of 3 Actions 1. Continue Without Changes 2. Continue With Changes Interventions Frequency/Duration Goals 3. Discontinue Care Not Too Little….Not Too Much 1. Too Vague Lack Necessary Components Just “Continue” 2. Too Specific Guarded with Specifics “Progress…as indicated” E.g. “Will progress resistance on Total Gym next visit as indicated” “Consider…” E.g. “Will consider increasing reps on Total Gym next visit” Case Example P: Will follow up for additional treatment 2x next wk; will continue with current exercise regimen but consider adding step downs; pt to continue with her HEP, will consider adding stairs to HEP; recheck R knee girth measurement at next session. Will send progress report to Dr. Smith  References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Documentation of a Visit, accessed 23 February 2024, https://www.apta.org/your-practice/documentation/defensible- documentation/elements-within-the-patientclient-management-model/documentation-of-a- visit Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Initial Visit SOAP Documentation Assessment Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the components that comprise the assessment portion of a SOAP note during an initial physical therapy visit 2. Recognize the process of transforming patient information from the examination into a coherent assessment and prognostic statement 3. Synthesize examination findings from a patient scenario to construct a well-organized assessment section of a SOAP note Examination à Evaluation Evaluation Assessment Interpret and Integrate Exam Findings Formulate a PT Diagnosis Develop a Prognosis Evaluation Components Systematic Approach 1. Intro to Client 2. Medical Diagnosis 3. Interpretive Problem List Impairments Limitations and Restrictions Contextual Factors 4. PT Diagnosis 5. Prognostic Statement Intro to Client and Medical Diagnosis 1. Brief Introduction to Client Name, Age, Sex, and Referral Patient Summary More for Review and Ease Grace Walker is a 69-year-old female May Be Automatic in EMR referred to physical therapy by Dr. Smith. 2. Medical Diagnosis Consider “Signs and symptoms consistent with…” Medical Diagnosis 2 weeks s/p R TKR "5/s consistent I PTsb not metically c... 8X Problem List Use ICF Categories to Integrate and Interpret Examination Data Body Functions and Structure Impairments Activity and Participation Limitations and Restrictions Relevant Personal and Environmental Factors Problem List Use ICF Categories to Integrate and Interpret Examination Data Unable to Body Functions and Structure Impaired Difficulty Plantarflexion Participate Impairments Strength Running in Race Activity and Participation Limitations and Restrictions Relevant Personal and Environmental Factors Problem List Use ICF Categories to Integrate and Interpret Examination Data Body Functions and Structure Impairments Activity and Participation Limitations and Restrictions Relevant Personal and Environmental Factors  Impairments Problem List R Knee Pain Body Structure and Function R Knee Effusion and Edema Impairments Decreased R Knee Joint Mobility and ROM Decreased R Knee Strength with Associated Thigh Atrophy  Limitations/Restrictions Unable to Walk or Stand > 10 min Difficulty with Stair Negotiation Problem List Decreased efficiency in transfers; sit to stand Activity and Participation Limitations and Restrictions Inability to do laundry; basement Unable to independently dress Les Limited community involvement; only going to medial appt Unable to travel  Personal Factors Problem List Motivated Personal Factors and Limited co-morbidities/generally healthy Environmental Factors Environmental Factors Laundry and craft room in basement of house Supportive husband  PT Diagnosis Diagnostic statement at the impairment, limitation, and restriction level Connects categories of “Problem Lists” together and ties in Medical Diagnosis Possible links to Personal Factors Environmental Factors ICD-10 Codes  PT Diagnosis what's PT Diagnosis Impairments mechanically wong? Impaired R knee joint function and R LE motor function with R knee inflammation and pain related to Activity recent R TKA leading to limitations in Limitations ambulation, stair negotiation, and independent dressing, as well as an what car Participation Restrictions inability to fully participate in younoely? same but community and leisure activities at previous level. on a commn- nity or wider scale ICD-10 Codes R26.89: Other abnormalities of gait and mobility M25.561: Pain in right knee M25.461: Effusion, right knee M25.661: Stiffness of right knee, not elsewhere classified M62.551: Muscle wasting and atrophy, not elsewhere classified, right thigh Z96.651: Presence of right artificial knee joint Z47.1: Aftercare following joint replacement surgery Prognostic Statement Predicted optimal level of improvement in function and amount of time needed to reach that level Considerations Current Level of Function vs. Capable Level of Function Chances of Achieving this Level of Improvement Contextual Factors Rehab vs. Medical Prognosis Excellent, Good, Fair, Poor Prognostic Statement CYA PT Prognosis Personal With skilled physical therapy, the patient Factors demonstrates good potential to address above impairments and limitations, achieve her rehabilitation goals; below, Environment Factors and return to community and travel activities without limitation due to her R Capable knee over the course of the next 6 Functional months as she is adherent to the Level physical therapy plan of care. In Summary Documentation Efficiency Systematic Approach Practice, Practice, 1. Intro to Client Knowledge Additional 2. Medical Diagnosis Practice 3. Interpretive Problem List Impairments Limitations & Restrictions Contextual Factors 4. PT Diagnosis 5. Prognostic Statement Documentation Concepts  References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Initial Examination and Evaluation, accessed 23 February 2024, https://www.apta.org/your- practice/documentation/defensible-documentation/elements-within-the-patientclient- management-model/initial-examination Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved. Initial Visit SOAP Documentation Subjective Michael Clarke PT, DPT Board Certified Orthopedic Clinical Specialist (OCS) Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) Learning Objectives 1. Identify the components that comprise the subjective portion of a SOAP note during an initial physical therapy visit 2. Recognize the process of collecting and documenting patient information in the subjective exam 3. Compose a clear and structured subjective section of a SOAP note by integrating information gathered from a patient scenario Examination Subjective Patient Statements Caregiver Statements Information from other sources Other health care providers Medical records Types of Data Gathered During Patient Interview Subjective Components 1. Demographics 2. Current Condition Chief Concern; “Complaint” Symptom Behavior Symptom History Level of Function 3. Medical History and Review of Systems 4. Social History 5. Patient Goals Demographics 1. Includes Name Physical Therapy Initial Examination Date of Birth; Age Medical Diagnosis Patient Name: Grace Walker Gender/Sex/Pronouns Date of Birth: 03/10/19XX Preferred Language Age: 69 Race/Ethnicity Race: Caucasian Sex: Female 2. Gathered From Medical Diagnosis: 2 wks s/p R TKA Intake Forms Medical Records 3. Documented Table Format (@ Top) Chief Concern - 1. Includes Why Patient is Seeking PT? “What brings you into physical Chief Concern therapy?” Instead of t Chief complain Right knee pain and stiffness 2. Gathered From preventing comfortable walking Intake Form over time and preventing community Interview involvement and travelling 3. Documented Heading and Short Phrase  Symptom Behavior 1. Includes Location Description Location: Centralized Low Back Pain with Intensity Occasional Numbness in R Foot Aggravating Factors Description: Achy Low Back Pain Easing Factors Intensity: Current: 2/10; Best: 1/10; Worst 8/10 NPRS Frequency/Duration Aggs: Bending, Lifting, Sitting 2. Gathered From: Intake Form Eases: Heating Pad, Lying on Back w/ Knees Bent Interview Frequency/Duration: Constant, Variable, Lasts 2 Hours After I Sit for Too Long, 2-3x/day; lasting 3. Documented ~30 min Headings and List Format Symptom Behavior Symptom Behavior Location: R knee pain, with occasional swelling around R knee, calf cramps on R Description: generally aching pain throughout R knee; occasional sharp pains at the front of the knee; stiffness Intensity: usual: 4/10; worst: 8/10; least: 2/10 Aggravating Factors: being on it too much (> 10 min standing/walking); stairs; moving it into end ranges; not moving it enough (like at night when sleeping); if it is bumped Easing Factors: icing; taking medication (opioids, NSAIDs); gentle ROM activities Frequency/Duration: aching and stiffness is constant; sharp pains are episodic depending on what she does, typically last for 5-10 minutes after an aggravating activity  Symptom History Typically five form at narra 1. Includes Mechanisms of Injury (MOI) and Disease Onset It Started I Have Timing and Pattern of Symptoms When... Seen… Prior Episodes Diagnostic Tests and Treatments 2. Gathered From Intake Form Interview Then This Now... Happened... 3. Documented Headings and Narrative Format  Mechanism of Injury/Timeline of Events Pt is 2 wks s/p R Total Knee Replacement (TKR); she states ~6 months ago she began having R knee pain; started Symptom affecting ability to walk, exercise, and travel as she normally History did; gradually worsened over time until her orthopedist recommended TKR. Following her TKR, she was hospitalized for 2 days, then d/c home where she had home health PT for the next 12 days; worked on transfers, walking, and general leg exercises (mini squats, heel slides, knee extensions). At her recent surgical f/u visit was told she was progressing well, and to follow up with outpatient PT  ppLs Level of Function 1. Includes Home, Work, School, and, or Social Previous & Current Level of Function 2. Gathered From Intake Form Interview 3. Documented Headings and Narrative Format Level of Function Previous: Prior to increased knee pain and now subsequent surgery, patient would regularly attend spin classes, hiked, did yoga every morning, and other forms of exercise; also travelled at least 2x/year; in the 6 months leading up to surgery Current: Patient able to ambulate independently, but is slow; states she needs to sit after 5-10 minutes of walking or standing due to knee pain/fatigue; able to negotiate stairs 1 step at a time; has only been leaving the house for medical appointments; is able to bathe, but needs dressing (pants and shoes/socks) assistance from husband Medical History 1. Includes Medical Conditions/Illnesses Related/Previous Injuries Surgical History Medications Allergies Medical Tests Review of Systems Relevant Family History Developmental History if relevant 2. Gathered From Intake Form Interview 3. Documented Headings and List Format Medical History Past Medical History Review of Systems Medical Condition: Borderline high blood Cardiopulmonary: no additional symptoms pressure, managed with medication; sleep Integumentary: states incision itches apnea; allergic to bee stings. and is still scabbed Medications: Norco PRN to manage the Gastrointestinal: pain meds have pain, with ibuprofen in between doses; led to some constipation Lisinopril; (see intake form for dosages) Genitourinary: no additional symptoms Previous Surgeries: Tonsillectomy, age 6; Musculoskeletal: aching at the L ACL reconstruction, age 22; R knee R knee; R leg feels weak meniscectomy, age 39; hysterectomy; Neuromuscular: notes some numbness age 44 around recent TKA incision Medical Tests: Pre surgical x-ray Cognitive/Emotional: no additional of R knee showed “bone on bone” symptoms arthritis, post surgical x-ray showed Other: recent weight gain over last 6 prosthesis correctly aligned months due to not being as active due to R knee pain; does not sleep well Social History 1. Includes Living Environment Characteristics Durable Medical Equipment (DME) Support; Family/Caregiver/Services Neighborhood Safety Occupation Activities & Participation Health Habits Support & Transportation 2. Gathered From Intake Form Interview 3. Documented Headings and List Format  Living Environment: lives with spouse in a 2-level home; 3 stairs to enter with handrail; 12 stairs to basement with handrail on R when descending; laundry and craft room in basement. Husband able to help with ADLs and IADLs; home health PT stopped last week Social History Occupation: Retired realtor; spent time traveling since retirement until R knee issues made that difficult; prolonged sitting with knee bent, prolonged walking Health Habits: Denies alcohol, tobacco, or other illicit drug use; has not been exercising regularly for 6 months, but has recently been doing a few knee exercises the home health PT prescribed  Patient Goals 1. Includes “What are your goals for physical therapy?” Putting Yourself on the same page as patient Patient Goals Patient, Family, and, or Caregiver Goals To be able to walk without an assistive 1. Gathered From device and return to going out more in Intake Form (perhaps) the community and eventually Interview (confirmed) travelling and exercise; decrease R knee pain; learn what more 2. Documented “I can do to get better faster Narrative Format In Summary 1. Demographics 2. Current Condition Chief Concern, “Complaint’ Symptom Behavior Symptom History Level of Function 3. Medical History and Review of Systems 4. Social History 5. Patient Goals References APTA Guide to Physical Therapist Practice 4.0. American Physical Therapy Association. Published 2023. Accessed 23 February 2024 https://guide.apta.org American Physical Therapy Association 2018, Documentation: Initial Examination and Evaluation, accessed 23 February 2024, https://www.apta.org/your- practice/documentation/defensible-documentation/elements-within-the-patientclient- management-model/initial-examination Kettenbach G, Schlemer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th Edition. F.A. Davis Company; 2016 © All rights reserved.