Physical Therapy Progress Note Example: Saving Your Time During The Appointment

According to Statista, the annual number of physical therapists in the United Kingdom has almost doubled from 2010 to 2021. Just look at these numbers:

In 2010 there were about 44 thousand physiotherapists, compared with 78 thousand in 2021

Demand always creates supply, that’s what we are documenting today. Not to mention, Medicare in Australia covers physical therapy sessions.

The more patients, the more overstrained providers’ workflows are. Healthcare providers are trying their best to make the treatment process easier to bear for everyone. That’s one of the main reasons for the growing accessibility and popularity of practice management software and its pre-made templates and questions.

Today we are about to discuss a simple but very productive way to lessen the tension during the appointment and to get more time for actual care - writing physical therapy soap notes using an example. You’ll find out:

1. Why we need treatment notes in physiotherapy
2. What is a progress note
3. The benefits of SOAP format
4. About Medesk physical therapy template

Let’s get started.

Why Do We Need To Write Physical Therapy Documentation?

Medical information should always be documented, especially when discussing a client’s progress. This simple rule gives a caregiver a range of advantages:

• Trackable health progress
• Structured information
• Urgent details can’t be omitted
• Easy transfer of the case to another specialist.

The process of transfer is very critical, because physiotherapy treatment is prescribed to the patient by the attending physician. And so, in a medical history, a note is made about the prescribed type of physiotherapy and the area of exposure.

It is critical to keep notes because a physiotherapist studies the patient's medical history, assesses the patient at the beginning of the treatment, and prescribes the method of exposure. In a medical history, he notes what physiotherapy treatment is prescribed for, the area of exposure, the type of therapy, and the number of procedures of physiotherapy.

Also, in a physical therapy progress note a professional writes down the tolerability of physiotherapy treatment, the number of procedures taken and their effectiveness. In the discharge summary, the attending physician evaluates the effectiveness of physiotherapy treatment and makes recommendations for further rehabilitation in outpatient conditions.

Progress Note: What Is It?

A physical therapy progress note is a legal document written by a professional occupational therapist. The aim of a note is to track a patient’s care process, write prescriptions, document complaints, and outline treatment plans.

Clinicians employ the instrument of note-taking to get the most out of the planning process. Every note includes a section called Plan that can be used to modify the treatment if needed. A therapist uses the planning section of a note to make these alternations without interrupting the actual manipulations.

According to Medicare, a progress report must provide an update on the patient's condition every 5-10 visits. An important thing to remember is that a progress note is not an independent part of a medical record. All medical documents are connected with each other, but the information in them must not be reproduced. The plan of care, visit notes, test results, and progress all work together to produce the best functional results.

The most widespread format of note-taking in physical therapy is a SOAP format. Let’s consider it in detail.

The Benefits of SOAP Format

While there are many ways a physical therapist can document patient progress, physical therapy SOAP notes are the most comprehensive and structured way to go. These notes are carefully kept in a patient’s medical history providing a detailed picture of his progress, regression, interventions provided and visits performed.

Developed by a physician and researcher, Dr. Lawrence Weed, the SOAP method makes it possible to prepare patient records with a clear goal in mind: well-being, recovery. Physical therapists use SOAP notes to describe in detail their interactions with patients and collect data on their success in physical therapy.

You can read about implementing this type of note in mental health practice here

SOAP is an abbreviation that represents four key sections of patient documentation:

Subjective section

The subjective part of notes summarizes the patient's perception of their condition, care and progress. A patient's description of their experience can provide useful information for medical professionals when making a diagnosis or tracking changes in their symptoms. The information in this section may include:

• Pain level
• Mood
• When did the symptoms appear or worsen
• Activity level
• Possible environmental factors.

The subjective section highlights how the patient's condition affects them. Physical therapists use the details in this section to document how physical therapy treatments change their overall quality of life. They can use subjective information to adjust the care plan to support patients' morale and meet their overall needs.

Objective section

Objective information describes the actions and measurements related to patient care. In this section, physiotherapists describe the methods they use to collect factual information about the patient, and the results of their methods. Listing objective details makes it easier for the physiotherapist to determine progress in physiotherapy procedures. Here are some examples of data that should be recorded in the goals for physiotherapy section:

• Vital signs
• Physiotherapy activities
• Duration of treatment
• Types of equipment
• Range of motion
• Power level
• Ability to balance
• Motor skills tests
• Flexion tests.

For example, if a patient has rheumatoid arthritis, the results of ultraphonophoresis, laser therapy, therapeutic exercises and peloidotherapy should be indicated in this section. Physioprophylaxis and different types of baths have been used to treat systemic scleroderma.

Assessment section

In this section, physiotherapists review the patient's condition and share their professional opinion on the patient's recovery status. Physical therapists can refer to past SOAP notes and identify changes to develop their assessment. This section combines and analyzes information from the first two sections to make predictions about the patient's recovery and assess the success of his current treatment plan. In this part you can specify:

• Brief description of symptoms
• Complications
• Interaction with other medical professionals
• Assessment of patient behavior
• Explanation of changes in physical abilities
• Forecasts of future progress

Plan section

The last part of the SOAP notes is the section of the plan where the physiotherapist describes the proposed treatment for future physiotherapy sessions. The physiotherapist explains to the patient the methods of treatment at home, referrals to other specialists, prescribed medications and plans for the next personal appointment. Describing their plan, physiotherapists point out each element of treatment and explain any changes compared to previous plans.

To cut it short, the idea is the following:

A clear benefit of splitting notes into sections is a convenient workflow during treatment.

What does it mean?

Writing notes makes it easier to follow all stages of the patient journey in your clinic: scheduling, examination itself, billing and patient satisfaction

Writing Physical Therapy Progress Notes Can Be A Simple Process!

Follow these steps to compose detailed and effective SOAP notes for physical therapy:

#1. Take personal notes

When treating patients, use shorthand to make personal notes about your interactions and observations. Since SOAP notes are detailed summaries of the appointment of a physical therapist, they require focus and dedication.

#2. Determine the goals of treatment

After the physical therapy session, start your notes by writing down your goals for the patient. Goals provide useful context for notes and allow you to quickly assess patient progress. Use specific numbers to describe success rates of treatment, such as walking 100 feet unaided or lifting 15 pounds.

#3. Use a narrative format

When filling out the main sections of a note, use a descriptive format to describe your findings. Tell a chronological story explaining the patient's experiences and what happens during the appointment. The narrative format helps to link each note to a comprehensive story about the patient's recovery through occupational therapy.

#4. Focus on the facts

Be honest when describing your observations. Keep a neutral tone to avoid making assumptions about the patient or passing judgments about actions, attitudes, or progress in treatment. Focusing on the facts of the situation in your notes preserves their integrity as a medical document and allows the care team to make logical choices.

#5. Use precise language

Include patient admission details so that other healthcare professionals can easily interpret their medical records. Briefly explain who performed each action, what equipment they used, and how you measured each action. Provide evidence for each statement and review them carefully to make sure the notes are clear and logical. Clarify any vague wording and organize your thoughts to make it easier for the reader to understand.

#6. Prepare notes

After filling out the SOAP note, add it to the patient file. Write down the date of the meeting and organize the notes in chronological order. They are most useful when you can easily access them to find out how a patient's physical abilities change in response to different types of treatment.

If you work with your patients remotely, you still need to take notes. But you have the significant advantage of switching from paper to electronic health records. Digital notes are easy to access and fill in due to the built-in progress note templates.

Digital Physical Therapy Template

If you want to make progress note-taking a time-saving process, you should take a closer look at practice management software with the function of electronic health records and pre-made templates for physiotherapists.

The advantages are too numerous to ignore:

• ICD-10 databases
• Uploading documents to medical history
• All plans and notes in one place, so the data is safe
• Function of automatically data adding
• Variety of forms and templates.

With an EHR system, you can devote yourself to the patient instead of being distracted by endless paperwork.

Previously completed consultation notes are a real magic wand.

For your convenience, the note is split into 3 sections:

1. Pre-treatment
2. Treatment
3. Additional treatment planning.

By filling in all the sections (which is very quick due to the pop-up options), you’ll have a comprehensive progress note within minutes.

Don’t forget that a clinician who doesn’t take his eyes off his papers is less likely to impress a patient, leaving you unsatisfied. By using a PMS, you can minimise errors and strengthen patients' trust.