SOAP notes: The physical therapy clinician’s guide

Ever heard the term “SOAP” being referred to in a professional health care industry setting? Are you familiar with what exactly it means? It’s used by health care professionals across the nation to document medical records and create structured and detailed notes. It’s meant to be a nationally universal method of note taking for medical providers, like physical therapists, to use while seeing their patients. The acronym was created by Dr. Lawrence Weed in the 1950s. Weed recognized a need for a standardized note-taking format in the medical and pharmacology industries. Thus, SOAP was created.

If you’re a physical therapist who is new to the acronym, keep reading below to learn about what the acronym SOAP stands for, the meaning of each word in the acronym, and why SOAP notes should be an integral part of a physical therapy practice’s EMR system.

What does the acronym SOAP stand for?

• Subjective.
• Objective.
• Assessment.
• Plan.

What is the meaning of each of the letters in the acronym SOAP?

• Subjective — The first letter of the acronym stands for subjective. This is where the provider notes anything subjective that they may discern from their patients. For example, a provider may want to put down their patient’s mood, symptoms, and the patient’s progress since the last meeting. This is the part of the chart where providers should note any of their observations about the patient’s behavior, their reported routines, their reported physical and mental situation, their reported medications, and their reported medical family history. These observations should be supported with evidence and should not contain bias or opinions without evidence to support them.

• Objective — The second letter of the acronym stands for objective. In the objective portion of the care provider’s note taking, there should be quantifiable, factual data. This section should include information like numerical data, or things that can be measured. This portion can also include behavioral observations, but they must be free from bias and be supported by evidence.

• Assessment — The third letter of the acronym stands for assessment. During the assessment portion of note taking, providers must use the information they collected during the subjective and objective sections and combine them to create a formal assessment. The assessment section should include the provider’s interpretation of how the appointment went. It should also include the patient’s understanding of what was covered during the appointment. Another important topic to note is whether the patient’s progress has quantifiably increased or decreased. It should not be repetitive information but should be the creation of a diagnostic statement based on previous observations. It must include a professional analysis, a clinical understanding of the patient’s issue, and clinical models used to interpret the patient’s issue in the analysis.

• Plan — The fourth letter of the acronym stands for plan. During this section of the SOAP notes, the provider should begin to create an action plan based on their analysis of the patient’s problems. It should include any changes made since the last created plan during the previous appointment, and any steps they’ll be instructing their patient to implement.

Why should SOAP notes be an integral part of a PT practice’s EMR system?

SOAP notes can be extremely helpful for physicians to keep organized and structured medical notes on their patients during each visit with a medical provider. Physical therapists should use SOAP notes to evaluate their patients, just as any other health care professional would do. 

Physical therapists should also know that SOAP notes can and should be an integral part of their practice’s electronic medical records (EMR) system. EMR systems are digitized systems of medical records, appointment information, and other necessary administrative and medical details that can be made convenient for all employees in the office. They’re designed to help care providers, like physical therapists, manage their clinics. 

If you’re a physical therapist, you’ll want to have your SOAP notes and your EMR system interconnected. This blending can help you more accurately quantify and measure your patients’ progress. It also allows you to seamlessly create follow-up appointments for your patients or update appointment cadences to better fit the information you’re putting in their SOAP notes.

AgileEMR can help your physical therapy practice prepare detailed SOAP notes

AgileEMR is a physical therapy practice management software solution, and it can help your team create and manage SOAP note sections within your medical records. Our solution is designed for physical therapists and with help from physical therapists. This unique input allows AgileEMR to address the biggest problem that physical therapists and PT practice back-office teams run into with run-of-the-mill clinical EMR systems: None of them were created with physical therapy at the forefront. 

Input from physical therapists has allowed our AgileEMR team to create an extensive, PT-specific library of document templates. In addition, our templates can be customized to your team’s specific needs, including adding sections for SOAP notes or other essential information. These benefits (and many more) are why AgileEMR has been used in more than 1 million patient cases by providers in the outpatient physical therapy industry.

Find out more about how AgileEMR can help your PT practice

If your PT practice is keen to learn more information about AgileEMR’s features and benefits, we’re here to help. We feel certain that our program can streamline the operations of your outpatient physical therapy and rehabilitation practice, and we want to help you learn how that is possible.

Contact our team today for more information or to schedule a demo to see how AgileEMR can help you streamline your practice’s operations.