Comprehensive Client Documentation with SOAP Notes
If you practice chiropractic, massage therapy, physiotherapy or any other healthcare discipline, you must document your treatments. Records should always be clear, consistent, comprehensive and up to date. Proper documentation of patient treatments is important. Many health care practitioners such as massage therapists, chiropractors, and acupuncturists use the SOAP Note format to standardize their client records.
SOAP is an acronym that stands for Subjective observations, Objective observations, Assessment and Plan.
The purpose of the SOAP Note is to document the client's condition and record their progress after each treatment. SOAP Notes can help practitioners track the effectiveness of treatment techniques and determine whether the treatment requires adjustment in future sessions. This helps to better address the client's problem areas next time.The four parts of a SOAP Note are:
SOAP Note - S is for SUBJECTIVEThe first section of the SOAP note contains subjective observations. These are symptoms the client describes to the practitioner. The subjective observations should include the client's descriptions of:
- The way they feel
- Past history
- Problem or injury details
- Current symptoms
- Limitations caused by the problem or injury
- What makes them feel better or worse
It is helpful for the practitioner to ask the client to rate their pain or discomfort on a level 1-10 with 10 being the worst. This allows the practitioner to see improvements or setbacks as time goes on.
SOAP Note - O is for OBJECTIVEThis part of the SOAP Note contains objective observations. Objective observations are symptoms that the practitioner can see or feel. The subjective observations should include the therapist's observations about the clients:
- General Weaknesses
- Joint Movement
- Skin Color
- Skin Temperature
- Muscle Texture
- Muscle Spasms
- Breathing Patterns
It is also useful to test the client's range of motion in different areas and track their changes from session to session.
SOAP Note - A is for ASSESSMENT
This part of the SOAP note documents the immediate results of a treatment. At the end of a session, the practitioner reanalyzes and documents the changes in the client's posture and range of motion.
The practitioner should note the amount of change that occurred by ranking progress. Either None, Mild, Moderate or Significant.
SOAP Note - P is for PLANThe last part of the SOAP Note is the treatment plan. The plan should include:
- Treatment Frequency Recommendations
- Home Care Instructions
- Recommended Exercises
- Reminders for Next Session
For many practitioners, effective notes can become a lot of paper to manage, but there is good news. Paperless storage with practice management systems such as Practice Jewel allow you to keep your SOAP notes online.
If your practice considering going paperless, getting started is easy. Our online SOAP notes tool is easy to use with a convenient copy function to save you time inputting similar treatments. Plus, your notes are backed up daily, so there is no offsite storage required.