Physical Therapy Business Tips

6 Tips For Writing Physical Therapy SOAP Notes

updated on

July 4, 2024

6 Tips For Writing Physical Therapy SOAP Notes

Writing physical therapy SOAP notes can be a confusing and mundane task without the right guidance. Whether we like it or not, well-written SOAP notes are critical to providing great patient care, billing for services, and protecting yourself legally as a provider.

To help you feel more confident with writing your documentation, we’re going to cover 6 of the most important tips to follow for clear, valuable, dependable SOAP notes that just might make you enjoy writing them a bit more. Let’s get started!

How To Write SOAP Notes For Physical Therapy?

Writing meaningful physical therapy SOAP notes is a task that requires a variety of skills. Some of the most important include personalizing the content of your notes, creating meaningful goals, setting a strong narrative, focusing on objective observations, standardizing terminology for other healthcare providers, and charting your notes reliably.

That’s a lot of changes to make at once, so let’s look closer at each of these tips individually.

1. Take Personal Notes

When it comes to providing great care for your patients, personalized treatments should be a major focus. Likewise, adding personal notes to your physical therapy SOAP notes can help you memorize important details about your patients, build rapport, and clarify important observations that might not stand out as well with standardized language.

Personal notes don’t always have to be detailed, but they should be memorable. For example, leaving a note as simple as “patient is interested in training for a marathon” can give you a gentle reminder to bring up marathon training to your patient during a future session.

2. Create Patient Treatment Goals

It’s often said that if you don’t know where you’re going, you’ll end up somewhere else. When striving to offer excellent physical therapy to your clients, patient treatment goals are an absolute must. Although there are many ways to write goals to guide the treatment of your patients, SMART goals are the most popular.

SMART goals are specific, measurable, attainable, relevant, and time-bound. Thinking about goals in this way and developing them in collaboration with your patient can help with boosting motivation and adherence to your plan of care, so make sure you’re creating SMART goals at your first visit and checking back on them frequently!

How To Write SOAP Notes For Physical Therapy

3. Use A Narrative Format To Describe Your Findings

Good notes should tell stories about your patient and their recovery journey, which is exactly why narrative formatting plays such an important role in high-quality physical therapy SOAP notes (more on SOAP notes later).

To effectively tell a story about your patient, it helps to start with who your patient is and what they’re dealing with, gradually moving to why they can benefit from your services, and finishing with what should be included in their plan of care or their next session.

4. Be Straightforward And Unbiased When Describing Your Observations

When writing physical therapy SOAP notes for your patients, it’s important to stay as objective as possible with your observations. While it can be helpful to include some of your opinions based on your clinical expertise and experience, they should be a supplement to your objective observations, not a replacement for them.

5. Make It Easy For Other Healthcare Professionals To Understand Your Notes

It’s important to remember that your patient’s plan of care can involve a number of other healthcare providers along the way. To help your clients get the best care possible, focus on writing your notes for physical therapy in a way that is concise and simple for other professionals to understand.

In some cases your technical knowledge as a physical therapist should come first, such as describing specific tests or observations. However, when it comes time to write assessments and recommendations for your patients, the language should be easily accessible to other healthcare providers with different training, such as medical doctors, chiropractors, and massage therapists.

6. Chart Your Notes

It’s one thing to write good notes, but how you store them can be just as important for physical therapists who want to provide great care. Charting your notes usually means digitally storing them in a safe and reliable physical therapy electronic medical record (PT EMR) system that allows you to share, modify, and easily access your notes throughout a patient’s plan of care.

What does SOAP stand for?

SOAP: What Does It Stand For?

The term SOAP note refers to a standardized note format with Subjective, Objective, Assessment, and Plan sections to capture all major components of a patient’s history and presentation, the provider’s observations, and a detailed treatment plan that can be modified throughout the patient’s course of treatment.

While physical therapists will be writing notes for physical therapy daily, SOAP notes are also the most universally adopted not format in the healthcare industry. This means that using a SOAP note format in your practice not only gives you a high level of standardization, but also makes your notes more easy to read and understand for other healthcare providers.

Whether you’re a generalist or a specialist who offers a variety of treatment packages, prefer to use premade templates or your own customized templates, or just want to give your patients the best notes possible for their plan of care, mastering the SOAP note format is an easy win for boosting the efficiency of your practice.

Template For Physical Therapy SOAP Notes

Using templates for your physical therapy SOAP notes is an effective way to simplify your note writing process, standardize your workflows, and save time in the clinic. ClinicSense offers a variety of free SOAP note templates that you can download and start using today to make your charting more enjoyable.

With a selection of helpful SOAP note templates to choose from for your practice, you can get your charting right every time and eliminate costly errors that can affect quality of care, payment for services, and the safety of your license.

What You Should Look For In SOAP Notes Software?

Being able to write SOAP notes in the modern world means using SOAP notes software that’s easy to use, customizable, and easy to integrate with your other practice management tools. Even more importantly, your notes need to be HIPAA and PIPEDA compliant to protect the sensitive information contained within them.

Knowing which physical therapy SOAP notes software is right for your clinic can be a challenge, but there are some options that stand out among the rest. ClinicSense is a powerful and easy-to-use physical therapy software that helps you take your patients from A to Z with standardized, concise, and reliable physical therapy SOAP notes - including free SOAP note template options.

ClinicSense helps you chart your notes quickly and easily, which means no more guessing what your notes should look like. You can get a SOAP notes free trial from ClinicSense today to start writing better physical therapy SOAP notes and enjoying more peace of mind with your charting.

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