therapy session

How to Simplify SOAP Notes for Physical Therapy

14 January 2023

January 14, 2023

In: Therapy Documentation Resources

therapy session

Highlights  

  • Your practice can streamline SOAP notes for physical therapy by using the documentation features in a cloud-based EMR.
  • Scoring grids, customizable templates, and goal libraries make documenting your patients’ progress easier and faster.
  • The SOAP notes can flow into billing, scheduling, and documentation to help you simplify your practice workflows.

SOAP notes for physical therapy allow you to document patient progress and inform you of the patient’s status. Keeping these notes formatted and structured with a physical therapy EMR ensures you organize your notes accurately and maintain communication with other providers. 

Importance of Maintaining Compliant SOAP Notes for Physical Therapy

Keeping a record of your patient’s condition and recovery journey allows you and their other healthcare providers to provide more personalized care. You can help your patient obtain an effective treatment plan by providing accurate SOAP notes for physical therapy. 

An inaccurate note may result in unintentional or potentially dangerous outcomes such as medication errors, unnecessary or incorrect treatment, and delayed diagnoses. The American Physical Therapy Association notes using unknown abbreviations to record patient information as a common SOAP note error. 

Errors can cause a breakdown in communication between providers or third-party compliance issues if you constantly use unfamiliar or confusing abbreviations. It can also result in regular payment denials.

With grids, templates, and features designed specifically for physical therapists, you can simplify the documentation process during your sessions. They can also help you streamline your practice management processes and ensure timely billing and payment from insurers. 

How ClinicSource Helps Simplify SOAP Notes for Physical Therapy

ClinicSource’s physical therapy EHR lets you reduce the time it takes to evaluate a patient and document your findings as part of the physical therapy process. It includes scoring grids, customizable templates, and goal libraries to help you enter formal and informal measures.

Scoring Grids

Scoring grids allow you to input parameters such as raw scores, confidence intervals, and percentile ranks. BOT-2, EIDP, and PDMS-2 scoring grids are available for physical therapy screenings and assessments. 

When you click the standardized assessment or test you wish to score, ClinicSource inserts the scoring grid into the template. You can create detailed reports for your patients by entering their scores into templates.

writing notes using a tablet

Customizable Features

Pre-formatted templates are available to enter case history, assessments, conclusions, and observations. Having access to modalities and CPT codes simplifies creating comprehensive treatment plans. These templates let you create readable assessment reports, boosting the chances of reimbursement from insurance companies. As new requirements emerge, your practice will be kept up to date automatically with new templates. 

You also have the choice of editing templates according to the needs of your practice and specific patients. For instance, you can document the necessary modalities for your patients’ needs, ranging from therapeutic exercise to electrotherapy. You can enter the medical equipment recommended to help your patients regain their physical strength and independence when necessary.

Goal Libraries

The goal library includes hundreds of physical therapy objectives applicable to your patients. These goal banks are customized for the most frequent areas of concern for physical therapy patients, such as strength, balance, ADLs, coordination, range of motion, and self-care. Once the information is selected, no additional data entry is required; the information flows directly to the patient’s daily notes.

Why ClinicSource is the Right Physical Therapy EMR

ClinicSource’s all-in-one physical therapy practice management software simplifies scheduling, billing, and documentation for your practice. It helps you streamline documentation and ensure timely and efficient workflows to increase revenue.

The platform features the following tools to boost your productivity and allow you to focus on providing excellent patient care. 

Seamless Collaboration Between Documentation and Other Functions

Physical therapy practices benefit from automatic collaboration among documentation, billing, and scheduling functions. Data instantly updates across all functions, eliminating redundant data entry and saving you time once spent on retyping notes and switching among different software functions. 

For example, when you choose an objective from the goal bank, it shows up in the patient’s treatment plan and daily notes. Their information, such as diagnoses, modifiers, and CPT codes, will also appear when you bill them and their insurer. 

Integrated Scheduling

ClinicSource provides an easy-to-use scheduling interface to display your monthly or weekly schedule. You can schedule therapy sessions using the fully integrated scheduling tool and track appointments by type to avoid missing critical appointments and double-booking for various physical therapists. 

The scheduler links directly to the patient’s record so you can review the history of every patient, including their SOAP notes. It allows you to keep notes on each patient, so it’s easy to access all SOAP notes for a client directly. You can quickly see their progress to help you prepare for their next session. 

Automated Billing and Insurance

Since ClinicSource’s billing feature integrates seamlessly with your practice scheduling and documentation, you won’t have to worry about using any other software or programs for online medical billing. All the data from your patient records and SOAP notes flows into your bill, ensuring accurate billing and coding. 

Additionally, a claims tracker will automate your insurance and billing processes, enabling you to submit and track insurance claims.

You can create batch statements from ClinicSource that include client balances and billing details. The patient statement generator can help you create documentation for patient records and to accompany claims. This tool simplifies the process of finding payment records and creating HIPAA-compliant statements.

Cloud-Based Practice Management 

ClinicSource’s cloud-based practice management system enables your practice to comply with HIPAA and your field’s standards without additional hardware or software. You can customize user permissions for every therapist and employee to access the scheduling, billing, and financial dashboards they need. 

All your patient data is secure and confidential on ClinicSource’s cloud-based servers. It also lets you view your patient’s records from anywhere, allowing you to document without using paper forms and clipboards. 

smiling woman at her desk

Streamline Your SOAP Notes for Physical Therapy with ClinicSource

Whether you are looking to streamline your SOAP notes for physical therapy or to automate the process entirely, ClinicSource can help. Created with therapists’ needs in mind, our cloud-based platform offers physical therapists a solution for recording their patients’ progress and helping them achieve the best possible outcomes for their health and well-being.

Our templates, SOAP notes, and other documentation features can help you support your patients’ recovery processes while saving time and boosting your practice’s bottom line.

Book a demo today to discover more about ClinicSource’s time-saving benefits for physical therapy practices.

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