21 April 2017

Therapy SOAP notes are an essential component of caring for patients in therapy practices of all kinds. Following every treatment session, it is vital to document data and information gathered from the patient encounter. Frequently, therapists utilize SOAP notes to monitor and document patient progress, log services, and communicate patient information to other professionals. With the high volume of patients seen on a daily basis, it is not hard to feel overwhelmed by therapy documentation. These six pointers will help you write SOAP notes more clearly and efficiently:

  1. Think about the purpose of the note
    Oftentimes, we complete so many SOAP notes that we forget why we do them. The purpose of a SOAP note is to communicate patient information and progress to other professionals, and to insurance companies for therapy billing
    Graphic of ClinicSource therapy SOAP notes template

    ClinicSource features therapy SOAP note templates that make your therapy documentation easier than ever


    and claims purposes. It also allows therapists to document the details of a session and provides rationale for ongoing services. It is important to evaluate which pieces of information are most relevant, making sure to include important details while avoiding unnecessary ones. ClinicSource therapy templates enable clinicians to utilize a consistent layout and format for documentation, resulting in SOAP notes that are cohesive and well structured.
  2. Complete notes within a reasonable timeframe
    Try to complete notes as soon as possible following any given treatment session. By finishing notes in a timely fashion, clinicians are less likely to forget details from a session. Additionally, falling behind on documentation can delay insurance reimbursement. ClinicSource templates automatically pre-populate basic patient information, allowing clinicians to spend less time typing basic information and more time documenting the specifics from a session. The time saved really adds up, allowing you to spend more time with more patients. This not only helps your patients, but also your bottom line.
  3. Double-check key details within your SOAP note
    Be sure to make the details of your SOAP note align. For example, if treatment was provided for a 60-minute session, then the start time, end time, and units billed should all be consistent. Review CPT codes to ensure that you are billing for the correct services. Make sure to use the correct patient name and diagnosis codes throughout your note. By using ClinicSource templates, accurate information flows automatically from section to section, greatly reducing the chances of unintended clerical errors. This ultimately increases the likelihood of reimbursement for your claims.
  4. Be mindful of meaningful goals and objectives
    Remember to create SMART (specific, measurable, attainable, relevant, and timely) goals and objectives. SMART goals and objectives ensure that all parties (patient, parents, insurance companies, physicians, etc.) understand exactly what is being targeted as well as the criterion for mastery. In a ClinicSource SOAP note template, goals and objectives from a patient’s treatment plan automatically populate in the Objective portion of the note, making it easy for the clinician to enter specific data points. By providing specific data points for goals and objectives, clinicians can easily track patient progress.
  5. Compare patient performance across sessions
    A lone data point does not provide much information by itself. However, when viewed in light of previous performance, data can indicate patient growth and progress. ClinicSource templates allow you to view data points from previous sessions, making it easy to add a comment about data trends to the Assessment portion of the note. In this section, be sure to analyze and interpret your data, especially as it relates to how a patient’s performance is changing. If needed, clinicians can generate a Progress Summary Note, which instantly graphs data from a selected time frame.
  6. Don’t underestimate home education programs
    Make sure to document home education programs and carryover within your SOAP note. Aside from helping patients to generalize their skills acquired in the clinic, several insurance companies have requirements regarding home education and programming. Be sure to document recommended strategies/interventions and how they are being implemented outside of your practice setting.

For a clinician, SOAP notes capture and document gains made during treatment sessions. While documentation might not be the most glamorous part of a therapist’s job, creating effective and meaningful SOAP notes is vital for patient care, as well as for claims reimbursement.

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