For providers taking appointments that are covered by patients’ insurance\u2014such as medical massage or physical therapy\u2014completing clinical documentation in the form of SOAP notes is a key component of the treatment process. SOAP notes completed for each appointment allow your patient\u2019s care team (which includes you!) to better understand their condition and track their progress. <\/p>\n\n\n\n
For future practitioners who work with your patient, your SOAP documentation can help inform their<\/em> treatment choices and enhance the patient\u2019s continuum of care.<\/p>\n\n\n\n This documentation is also a crucial factor in health insurance processing\u2014it helps ensure the patient will have their treatment covered by their plan.<\/p>\n\n\n\n This easy-to-use system is designed to help you assess your patient\u2019s unique needs, explain their treatment, and map out a care plan for achieving their recovery goals. With Zeel you can complete your notes right in the Provider App.<\/p>\n\n\n\n SOAP stands for Subjective<\/strong>, Objective<\/strong>, Assessment<\/strong>, and Plan<\/strong>. In some instances, you\u2019ll also have a section detailing Treatment<\/strong>.<\/p>\n\n\n\n The Subjective and Objective portions of an evaluation take place at the start <\/em>of an appointment, before you\u2019ve begun treatment. You\u2019re collecting information that will inform your therapeutic choices for the treatment you’re about to provide. <\/p>\n\n\n\n The Assessment and Plan portions are completed after a session has ended<\/em>, since they contain information gathered during<\/em> treatment, along with your future recommendations.<\/p>\n\n\n\n The Subjective entry consists of information the patient gives you<\/em>.<\/strong> That could include an injury they’ve experienced, pain they are feeling, the severity of pain, and how it might be affecting other areas of their life, such as their sleep or ability to perform daily tasks.<\/p>\n\n\n\n Avoid adding your own assessments and interpretations to this section\u2014this is the patient\u2019s opportunity to tell his or her own story as they<\/em> experience it. The Zeel Provider App makes the Subjective entry easy by providing a series of evaluation tools to document the patient\u2019s condition and symptoms.<\/p>\n\n\n\n The Objective entry consists of your impartial observations of the patient\u2019s condition.<\/strong> In a general clinical setting, that would include things like patient temperature or weight. As a massage therapist, you might observe characteristics such as posture, range of motion, or soft tissue tension.<\/p>\n\n\n\n The Assessment section is completed immediately after the treatment has ended.<\/strong> Here you\u2019ll detail your overall findings, based on your prior evaluations and the treatment you\u2019ve just provided. Be sure to make note of how the patient responded to this particular treatment and, if you\u2019ve seen them previously, how they are progressing in their recovery.<\/p>\n\n\n\n The Plan portion of your SOAP note looks forward<\/strong>. It should include steps to be taken in the patient\u2019s course of treatment, such as future treatment recommendations or changes to an existing course. Think of your plan entries in terms of goals\u2014they should be measurable and include an approximate timeframe to achieve them.<\/p>\n\n\n\n Note that in a patient\u2019s initial evaluation, your plan should be more detailed, as you\u2019re planning for a patient\u2019s full course of treatment. Follow-up plan notes can be shorter, and may be as simple as continuing the current treatment course.<\/p>\n\n\n\n If you are required to fill out a Treatment section, describe the treatment you just provided<\/em><\/strong>. You should include specific modalities or techniques, the exact body parts treated, and which side(s) of the body you worked on.<\/p>\n\n\n\nWhat Does “SOAP” Mean?<\/h2>\n\n\n\n
Unpacking the Acronym<\/h2>\n\n\n\n