6. SOAP Notes

why do we document?

• Client care management

• Treatment team communication

  • What's the PT working on?

  • Way to communicate in one place about the client

• Evaluations

• Progress notes

  • What's occurring?

• Discharge summaries

• Daily notes

• Physician orders

• If it wasn't documented, it didn’t happen!

supervisors/insurance may look at notes to say is it:

• Appropriate

• Medical necessity

• Law abiding

• Utilization Review

  • After services provided

• Utilization Management

  • Takes place while patient is active such as D/C planning and physician monitoring.

inpatient care in hospitals and critical access hospitals, skilled nursing facilities (SNFs), home health care, and hospice

medicare part A

Covers physicians’ services and outpatient care, including OT, also services in SNF when the client does not qualify for skilled coverage under Part A

medicare part B

Private insurance companies contract with Medicare to provide individuals with Part A and Part B benefits through Medicare Advantage Plan

medicare part C

prescription drug coverage

medicare part D

why do we need to know the payment sources when documenting?

ex: If client was injured at work and workers comp is paying, we have to document on how they are doing their job, not parenting their child

general guidelines for documentation

• Include:

  • Date and time

  • What services were provided and when they were provided.

  • What was said and what happened

  • Why the skill of an occupational therapist was required rather than the services of an aide, a family member, or another professional.

why is good documentation important?

• Someone else will read this and will have to understand what you wrote.

• people cover you for vacation and sick time

• This entry will be scrutinized by insurances

• Can be read by a Medicare reviewer

• Is what we documented reimbursable

• My client or patient can ask to read what I wrote.

how do you correct errors on documentation?

strikethrough

what are special situations?

• client refuses therapy

• absences

• incidents/accidents

• client sick

SOAP Note

S-Subjective

O-Objective

A-Assessment

P-Plan

• Patient report of problems, limitations, and needs

• Brief, couple sentences

• Relate subjective to what you're doing

• Initial evaluation should be longer

• Initial Interview

subjective (S)

• Health professionals observation

• Measurable

• Quantifiable

• Observable data

• No speculation on your part, just what you see

objective (O)

• The occupational therapist’s interpretation or assessment of what happened

• Analysis of the subjective and objective sections

• Put our feedback

assessment (A)

• What to do next

• Frequency

• Duration

• Goals

plan (P)

what is included in a discharge summary note?

• Goals met

• Client no longer making functional gains requiring skilled OT

• Client moves to another location

• Setting does not match the individual’s needs

• client and caregiver education

• home exercise program

A service must have been provided for at least 8 minutes to bill one 15-minute CPT code. A second billable unit cannot be billed “until you have at least 8 minutes past the 15-minute mark

8 minute rule