Understanding Medical Record Documentation and SOAP Notes

The SOAP Note Model

While there are many formats for documentation—including flow charts, checklists, and narrative styles—the most common organizational model used in healthcare is the SOAP note.

The SOAP acronym stands for Subjective, Objective, Assessment, and Plan.

Subjective (S)

The subjective portion contains information gathered directly from the patient, their family, or their caregivers. This is the patient's "story." It includes their chief complaint, pain levels (location, type, and scale), their home situation, and their personal goals.

Objective (O)

The objective portion consists of measurable, observable data—often referred to as "tests and measures". This is where you record what you actually see and measure during the session, such as:

• Range of Motion (AROM/PROM)
• Strength testing
• Functional abilities (e.g., bed mobility, gait, or balance)
• Standardized test scores

Assessment (A)

The assessment is the professional interpretation of the subjective and objective data. During an initial evaluation, the Physical Therapist uses this section to determine the PT diagnosis (the impact of impairments on function) and create a problem list.

Plan (P)

The plan outlines the next steps for patient care. It includes the specific interventions to be used, the frequency and duration of treatment, the patient's prognosis, and the schedule for re-examinations.

Exam Tip: Remember that while PTAs assist in the examination portion, they do not perform the initial evaluations. The PTA is primarily responsible for the daily notes that follow the initial evaluation.

Professional Standards for Writing

To ensure your documentation is professional and legally sound, you must adhere to specific rules regarding style and mechanics.

The Four Pillars of Documentation

1. Accuracy: State exactly what is seen and known. Use accurate spelling.
2. Brevity: You do not need to write perfect, flowing sentences. It is acceptable—and often preferred—to use sentence fragments to save time.
3. Clarity: If you are handwriting, your notes must be readable. If a note cannot be read, it is legally as if it was never written.
4. Timeliness: Complete your notes as soon as possible while the information is fresh. This reduces the risk of inaccuracy.

Essential Rules and "Don'ts"

• Use Black Ink: Always use black ink for medical records.
• Date and Time: Every note must be dated and timed. Use the 24-hour (military) clock to avoid confusion.
• Signatures: Always sign your full name and credentials at the end of every entry.
• Mistakes: Never use white-out or erasable pens. If you make a mistake, draw a single line through it, then initial and date the correction.
• Avoid Self-Reference: Do not use "I" when writing. Instead of saying "I performed gait training," use "PTA performed gait training".
• No Blank Spaces: Do not skip lines or leave large blank spaces at the end of a note, as this could allow for unauthorized information to be added later.

Person-First Language

A vital aspect of modern medical documentation is the use of person-first language. This means you should never define a person by their medical diagnosis or physical limitation. Instead, your documentation should emphasize the person's identity.

By focusing on the person rather than the pathology, you maintain professional dignity and respect for the patient within the medical record.