Physical therapy notes are documents used by physical therapists in the form of soap notes which include Subjective, Objective, Assessment and Plan. These notes record information about the progress of the patient and a professional medical transcription company can deliver accurate transcripts for hospitals, outpatient clinics, group practices and individual physicians. Converting physical therapy dictations or notes into proper and accurate medical records is vital to ensure appropriate patient care, accurate medical claim submission, and efficient administration of hospitals. A good transcription service understands the working environment of the physical therapist and their need to maintain accurate medical records.

What Do You Mean by SOAP notes?

Physical therapy SOAP notes contain details about the condition of the patient, and the treatment to be provided. It should also include the frequency, duration and the equipment used for treatment. The progress of the patient and the response towards the treatment may also be mentioned in the physical therapy notes. With all this information, it provides an outline of the course of treatment provided that are later transcribed. Here are some tips to write SOAP notes for physical therapy.

SOAP refers to Subjective, Objective, Assessment and Plan. According to the American Physical Therapy Association the Physical Therapist SOAP notes should include:

• Self-report of the patient
• Information about the specific intervention provided
• Equipment used
• Changes in patient health
• Any drastic reactions or changes
• Progress
• Communication with other physicians or other healthcare professionals

Let us consider the 4 Parts of SOAP notes

• Subjective: This part includes every detail about what the patient has to say about his/her health condition. It provides insights about how the patient feels about his/her progress, whether they are able to function well and whether their quality of life has improved. It also includes the patient’s description of pain, dizziness or any other discomfort. Sometimes patients may not have any opinion about their treatment. So when required, it is useful to take subjective opinion from the family members too.
• Objective: This includes all the pertinent measurements like vital signs, range of motion, muscle setting measurements and so on. The therapist should also include frequency, duration and the equipment used. Although this document does not have much legal value, all details should be accurate as it determines the treatment.
• Assessment: It includes all the impressions from the physician regarding the patient’s health condition. In this document, the physicians must explain how they have decided about the treatment, and how they intend to work with the patient. This is the document where therapists record their professional take on each session, therefore it holds legal value.
• Plan: This is the final step which mentions all the details about what treatment plan is set for the patient. It also has the development of the patient’s treatment plan.

Advantages of Writing SOAP Notes

• Act as Proof: Accurate SOAP notes serve as proof of interaction between the doctor and the patient. It covers all basic details like date, time, and location that are relevant. It also includes different types of treatment. The physical therapist may use these SOAP notes if they work with patients who may need extra level of documentation for legal purposes.
• Useful for Future Reference: SOAP is a detailed report of treatment that allows medical professionals to build their own mini-research library. SOAP notes help to collect data that can be used as reference throughout a patient’s journey.
• Information can be Shared among Peers: SOAP notes are widely accepted as the easiest type of medical record-keeping when it comes to sharing information among peers. SOAP notes play a huge role in ensuring clear communication regarding the patient across all healthcare team members.

A good transcription service provides accurate medical records for conditions associated with back pain, sports injury, cerebral palsy, frozen shoulder, osteoarthritis of the foot, strains and sprains. An experienced and reputable provider of medical transcription services can be of great support in preparing SOAP notes for physical therapists, ensuring confidentiality of patient data while also maintaining security policies.

Medical records are a combination of both self-reported patient information and physicians’ notes on the diagnosis, care and treatment given to the patient. When a patient visits a physician, he or she diagnoses the patient and dictates the patient’s medical condition via a digital recording machine. Medical transcription services transcribe these recordings into accurate medical records and via HL7 interface the transcription vendors can access the physician’s EHR and upload the information. Medical records should be documented in a timely and error-free manner.

The need for accuracy in medical transcription is rising rapidly. This is due to increased demand for medical documents to ensure quick and efficient patient care. It helps the healthcare providers to come up with the most appropriate treatment plan and correctly follow it. Accurate medical records not only improve the quality of care, but also help increase revenue.

What is the Reason for Poor Documentation?

According to an article by Promptemr, $10.7 billion worth software problem in physical therapy was caused by bad software, leading to indefensible documentation and bad billing processes. This not only affects the health of the patients but also results in loss of revenue for the medical organization. Another blog published in www.rightpatient.com stated that patient identification errors have been a long-term issue in the US healthcare system.

Significance of Patient Identification

It is estimated that every year, around 195,000 deaths occur because of medical errors. Patient identification errors are a major concern in this regard. Identity theft also leads to financial loss for patients. For instance, a person who did not undergo a particular treatment could receive a bill stating that they did. Patient identity may sometimes get mixed up due to common names, age, DOB etc. This can cause a ripple effect and damage the reputation and credibility of the healthcare organization. The right solution to this issue is to improve the accuracy of medical records by hiring a reliable transcription vendor.

Documentation Tips for Accurate Medical Records and Better Revenue

Accurate medical documentation is important to protect the patient’s health. It promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. With duplicate or inaccurate medical records, larger hospitals can have more than a million records stored in their EHR systems that are of no use. It leads to mistreatment, wrong medical decisions, and wrong medications, based on inaccurate or incomplete medical history arising from duplicate records or overlays. If the patients are identified before any service, the right patient will receive the right treatment. This will help the healthcare organization to save millions of dollars.

• Set Achievable and Measurable Goals: The most common cause for denial of the claim in physical therapy is poorly documented treatment goals. So, the goal must be measurable and impact the patient’s daily life to be defensible and justify continued skilled treatment. Examples:
  • Inaccurate: Improve Right Shoulder Range of Motion – 6 Weeks
  • Accurate: Improve Right Shoulder Flexion Range of Motion by 20% to allow patient to reach into kitchen cabinets – 6 Weeks
• Consider Objective Measurements more Frequently: Documenting objective measurements every time a patient visits may be of no use, as the patient’s measurements may be identical. Increasing the frequency of your objective measurements will however, allow you to prove your value to your patient and get them to continue going to therapy.
• Track and Show Progress on Flowsheet: Illegible flowsheets impact the ability to treat your patients, and it can also lead to claim denial. Another issue it that it is not possible to use flowsheet to show a patient how much they progressed. An electronic flowsheet which is easy to use is a useful tool that help you get paid and also help you retain patients longer.
• Document on the Same Day: Make sure to complete the documentation while you treat the patient. The ideal practice is to have the patient fill in his/her chief complaint, primary concern, and pain levels for the day. This practice helps to create defensible documentation that is accurate and saves you from getting behind on your notes.

Accurate medical documentation is an essential element for any hospital, clinic or healthcare unit, and a professional medical transcription company can help ensure this. It consists of all important information from the admission of the patient till his or her discharge. These records become useful for the patients as well as the healthcare providers for future visits.