Best Practices for Effective Occupational Therapy SOAP Notes

24 May 2015

diagram-flowchartOccupational therapy SOAP note templates are key to having a truly successful EMR in your office, and it is an important consideration when you are choosing a system. Some preselected formats are easier to use than others, but there is no one size fits all template and a lot of your success will depend on your ability to adapt a system like ClinicSource to your patients.

There are basic questions to ask, and the more diverse your practice, the more templates you will need. If you are offering occupational therapy services primarily to seniors suffering from one particular problem, then you could most likely get away with just a few select templates. But if you are serving a wider array of patients from all age groups and with a variety of treatment plans, you might need dozens of SOAP notes for occupational therapy templates.

Depending on the clinic, some therapists may do better when they can shape their templates to their own personal needs. Here are a few key things to keep in mind to get the most out of any templates provided to you with an EMR.

Determine How You Want to Write Your Therapist Notes

There are infinite ways to write effective therapist notes and some are more unique to certain therapists than others. Depending on how many therapists need to access any one set of notes, you may want to go one of two ways. Of course, you need your therapists to meet the basic requirements set by the insurance companies. But beyond that, how much flexibility do you want them to have?

If you want your therapists to be able to create new templates for their notes on the fly, you will want a system that is more flexible. On the other hand, if you want therapists to follow a certain prescribed format to make notes easier for any therapist in your office to read, you will want to create a certain number of templates and then give your therapists the option to use the ones they need for each patient. Just click here to read more about the many available options.

You may want to start out with more flexibility, allowing your therapists to submit possible templates as they work. Eventually though, you will want to solidify certain standard templates to keep your office organized. For some smaller offices, this may mean talking to the company hosting your EMR system about standard templates that they offer and selecting a wider variety for therapists to utilize.

Make Sure That You Have a Standard Naming Process for Your Therapist Notes

Especially if you are going to create a lot of different templates, it can be easy for therapist notes to get out of hand. If you plan to have your therapists use certain templates for certain types of patients, it will be essential to keep your templates organized with similarly formatted names.

Make sure that your therapists can quickly find what they are looking for without having to guess what 5 different therapists may have named it. The idea behind an EMR is to make your office more efficient, and this is a key part of patient care.

Do You Want Your Occupational Therapy SOAP Notes to Be Blank or Pre-Populated?

Before you make any impactful choices, you will want to determine one thing: do you want your occupational therapy SOAP note to be pre-populated or blank, with certain designated sections?

Pre-populated templates can speed up the note taking process, and you can still adjust the pre-populated fields as you put the systems into practice. SOAP notes are the most basic template you will need for every patient, but your decision can be applied to any template.

Personalize Everything from Therapist Notes to Scheduling and Billing to You

One of the biggest concerns a therapist faces is the idea that an EMR will interfere with effective patient care. Features like ClinicSource Scheduler and billing can be assigned to office staff, but therapists should be responsible for the occupational therapy SOAP occupational therapy note. With SOAP occupational therapy notes, the obvious answer is to personalize templates to fit your needs and make the note taking process natural and more efficient.

However, you should not forget about the billing, scheduling, and other features of EMR. If you use the right EMR system to its full potential, your whole office will serve patients more effectively and make your billing process more efficient. Therapy notes are an integral part of the process, but ultimately it is just one part of that process.

Learn more about everything that an EMR can offer you, and the diverse options you will find when you use ClinicSource.

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