How to take good physical therapy notes

Physical therapy notes, commonly referred to as SOAP notes, are a tool for documenting a patient’s progress throughout the course of their treatment. Comprehensive, well-organized notes will let you know whether your treatment plan is working for the patient or not. They can also be passed on to the patient’s other providers with their medical history.

In this article, we’ll discuss how to take strong physical therapy notes. We’ll also discuss the most effective strategies for managing these notes. Keep reading to learn more.

What is the value of good physical therapy notes?

In-depth, organized notes carry many benefits for physical therapists. Here are just a few of them:

• Serves as a record of treatment — For one, well-taken notes serve as records of your patient interactions. They show the date, time and location of each session while at the same time providing details about the treatments you administered, your assessments of patient injuries and more. This can be helpful for both you and any other health care professionals who treat the patient in the future.
• Provides data on treatment strategies — When you keep comprehensive treatment notes on each patient, you essentially build a library of data you can refer back to later. You can use this information to learn about which treatments work best in certain scenarios.
• Creates information for sharing — Physical therapy notes can easily be transferred to a patient’s other health care providers to help them provide more optimal care. Their other physical therapists, as well as their doctors, will know exactly how you diagnosed them, which treatments you administered and the success of those treatments.

Understanding SOAP

The “SOAP” in SOAP notes stands for “subjective, objective, assessment, plan.” You should make sure to cover each of these components in your therapy notes:

• Subjective — Start by documenting the patient’s progress from their point of view. How do they feel about their condition, their recovery and their quality of life? 
• Objective — Move on to your own objective observations. This section should include any measurements, including vitals and details on any treatment methods or equipment used.
• Assessment — This section is used to document patient progress for legal purposes. You should explain your justification for all diagnoses, treatments and decisions regarding the patient. Your notes should show how you determined the course of treatment, how you set goals for the patient and why you’ve made specific decisions throughout the treatment process.
• Plan — This section should outline how you plan to help the patient achieve their treatment goals. What will you do with them in each session, and what will you ask them to do in between sessions to help supplement their treatment?

With all of this information document in depth, you’ll have a strong record of the patient’s treatment to refer back to if you ever need to in the future.

How to manage your physical therapy notes

An electronic medical records (EMR) system makes it easy to manage your SOAP notes and other physical therapy documentation. These systems allow you to input your patient notes directly into an electronic document that can be accessed online anytime. It completely eliminates the need for paper records, freeing up a whole lot of space in your office.

Even better, an EMR system can help to ensure that all of your SOAP notes are complete and compliant with medical regulations. This helps cut back on costly human errors and regulation oversights. Some systems (like AgileEMR) even feature templates to help you create a streamlined and professional documentation system.

AgileEMR could be a valuable tool for your clinic

AgileEMR is designed to meet the specific needs of physical therapy clinics. Not only can our software help you create and manage your patient notes, but it can help you with billing, task management, scheduling, reporting and more. Our system compiles all of the data you input to create a holistic picture of your business’s health and your patient journeys so you can make smarter financial decisions and provide the best possible care for your patients.

Contact our team today for more information or to schedule a demo to see how AgileEMR can help your practice.