Week 2: Documentation/Soap Writing

Patient Care Notes

• record what the therapist does to manage the individual patient's case

• can be used in outcomes research

Disposition

• last/present status of pt

• after every session based on Sx. of pt

• based on objective findings and response therapy

Initial Evaluation

initial note written after pt.'s first examination and evaluation, documents history, examination, evaluation, diagnosis, prognosis. and poc; need for pt's referral; goals, problem list.

Progress Notes

written periodically, recording results of examination and re-evaluation, changes in prognosis, poc as needed.

Discharge Notes

PT discontinued care, pt is discharged from therapy, after a final exam and evaluation is performed.

PT Notes

irregular documentation of pt's, in between sessions, documentation of what transpired during session, SOAP format, w/o history taking.

Subjective Objective Assessment Plan

SOAP

Subjective

includes CC of pt, HPI, Family Medical, Personal, and Environmental History.

Objective

results from pt.

Assessment

summary from subjective and objective parts.

Plan

what they need to do w/ pt. based on evaluation.

General Information

being taken bc it is needed for pt's demographic info/identifying information, can help identify what lead to that injury, etc.

Chief Complaint

• should be specific area, pain scale, what type of pain, etc

• PT should know what to do functionally, and what pt can't do functionally

Patient Goals

PT should know pt's goal.

History of Present Illness

details pt’s CC from w/c they are seeking medical attention as well as unrelated functional deficits, should explore other info related to CC such as recent and past medical/surgical history, complications of treatment, potential restrictions/precautions and mechanism of injury.

Ancillary Procedures

medical tests, results affecting pt’s condition or treatment ex: xray, mri, ct scan; aligned to pt’s condition, specific and sensitive to pt’s condition.

Medical/Drug History

drugs taken by pt in relation to injury, as well as supplements and maintenance drugs.

Past Medical History

present or recent diagnosis outside present injury.

Family History

hereditary diseases, sensitive to cases to systemic or neurologic in nature.

Personal, Social, and Environmental Hx

talks more about set up of pt.

Objective

• results of tests and measures performed and the therapist's objective observations of the patient are recorded

• measurable or observable information used to formulate the plan of care

• repeatable

Examination

• used to confirm or refute the suspected diagnosis, which is based on the history and observation

• must be performed systematically with PT looking for a consistent pattern of S/Sx that lead to a differential diagnosis

Stereognosis

ability to recognize objects helped by the hand without vision.

Barognosis

ability to recognize weight.

Cadence

number of steps per minute.

PT Impression

contains the patient’s MD diagnosis, a summary of all the impairments listed in the O part, and its implication to the patient's level of function.

Problem List

• a list of all the impairments noted in the observation section

• list of complaints of the patient or the problems that you found in the assessment. This includes the subjective and objective measurements

Prognosis

include justification for further therapy for a patient who initially appears relatively independent with one functional activity as well as the projected level of improvement based on patient and case related factors./

Prognosticating Factors

basis how to determine the prognosis of the pt.

Positive Prognosticating Factors

facilitate patient's recovery.

Negative Prognosticating Factors

hinder patient's recovery and improvement even with therapy.

Long Term Goal

• describes the final product to be achieved by therapy

• these outcomes are listed in terms of function

Short Term

are interim goals that needs to be achieved to be able to achieve the long term goal.

AUDIENCE BEHAVIOR CONDITION DEGREE

ABCD of goal writing.

Audience

almost always, the patient is the audience. However, it can be a family member or the patient with family member.

Behavior

• is always an action verb, often followed by the object of the behavior

• the object of the behavior must be something that can be measured or described accurately so that you can document when these outcomes are achieved

Condition

includes the circumstances under which the behavior must be done or the conditions necessary for the behavior to occur.

Degree

• it includes the minimal number

• the percentage or proportion

• any limitation or departure from a fixed standard

• any distinguishing features of successful performance

• this should be realistic, measurable, and observable in term of function

Specific Measurable Attainable Realistic Time Bound

a goal must be SMART

Plan

contains all the pt management as well as the time frame and schedule that the patient will be seen and treated.