Therefore, it is your professional responsibility to make sure that it is well-written. Communication with other providers of care, the patient and their familyīear in mind that your report will be read at some point by another health professional, either during the current intervention, or in several years time.Details of the specific intervention provided.However, the American Physical Therapy Association does provide the following guidance on what information should be included : There is no policy that dictates the length and detail of each entry, only that it is dependent on the nature of each specific encounter and that it should contain all the relevant information. While documentation is a fundamental component of patient care, it is often a neglected one, with therapists reverting to non-specific, overly brief descriptions that are vague to the point of being meaningless. Having said that, the format is not so rigid that it cannot be adapted to take this into account. One major difficulty with SOAP notes for physiotherapists is the lack of guidance on how to address functional outcomes or goals. They feel that the emphasis on the problem-orientated approach to documentation is misplaced and that it is not conducive to clinical decision-making. Delitto and Snyder-Mackler (1995) have also suggested that a sequential, rather than an integrative approach to clinical reasoning is encouraged, as there is a tendency by the health professional to merely collect information and not assess it. However, the format has also been accused of encouraging documentation that is too concise, overuse of abbreviations and acronyms, and that it is sometimes difficult for non-professionals to decipher. It also emphasizes clear and well-organized documentation of findings with a natural progression from the collection of relevant information to the assessment to the plan on how to proceed. Quinn and Gordon (2003) suggest that the major advantage of the SOAP documentation format is its widespread adoption, leading to general familiarity with the concept within the field of healthcare. However, various disciplines began using only the "SOAP" aspect of the format, the "POMR" was not as widely adopted and the two are no longer related. Each SOAP note would be associated with one of the problems identified by the primary physician, and so formed only one part of the documentation process. Lawrence Weed in the 1960's at the University of Vermont as part of the Problem-orientated medical record (POMR). Plan - How the treatment will be developed to the reach the goals or objectives.Assessment - The therapists analysis of the various components of the assessment.Objective - The therapists objective observations and treatment interventions.Subjective - What the patient says about the problem / intervention.They are entered in the patient's medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process. SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional.
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