Title: Documentation
Course: PHT 1007 Topics in Physical Therapy > Section: Module 11

Introduction

In this module, we will be discussing the importance of documentation in the field of physical therapy.  Documentation of the care you provide is critical, and you must be able to show that your selections are effective in producing the outcomes desired for each of your patients. A lack of progress may lead to a lack of payment for the services that you provide to your patients.
Documentation is very important in the profession of physical therapy as this is how we communicate with a variety of people. Documentation may be reviewed by your coworkers and peers as well as insurance companies and lawyers. Your documentation tells the reader what is happening with the patient. It basically tells a story:

- what is the history of the patient's problem
- does the patient have pain--if so how could you describe it
- does the patient have physical limitations
- do these limitations affect the patient's ability to work or to function on daily basis
- what interventions are being used to address the limitations
- are the chosen interventions producing positive outcomes
- what are the goals of therapy
- is the patient making progress toward these goals

As clinicians, we must be able to clearly communicate what we are doing and why we are doing it. We must also be able to show that what we are doing is working to help the patient to achieve their goals. You cannot keep doing something simply to occupy your time.  Your ability to communicate all of this in a clear and easy to understand method could be the deciding factor as to whether a patient can continue with the therapy or whether services are even billable.

This week, you will have the opportunity to practice SOAP note writing and gain some confidence in what is supposed to be documented and where it belongs in a note. This will be a basic introduction to documentation and we will touch on it again later when you start in the technical phase of the program.  You will have plenty of opportunity to practice documenting before you go out into the clinics and do it in a live situation. Your textbook does a good job of identifying what types of information goes into each of the sections of the traditional SOAP note.  I am also including as part of this week's information a nice handout entitled Guidelines for Documentation.

You will have 2 assignments to complete this week. One is a documentation exercise. The second assignment is writing a SOAP note. I am including the link to the assignments in this week's content. You should be able to type right into the document. You can then save it and submit it into the Assignment Folder under the appropriate link.

Objectives

To successfully complete this module, you will be expected to:

- describe the significance and purpose of documentation in physical therapy
- discuss and identify elements of documentation
- define the SOAP mnemonic and its meaning
- correctly identify components of each section of a SOAP note
- develop an appropriate SOAP note with relevant information in the correct section

Readings

Chapter 10 of the textbook

Module 11_Documentation Lecture.pdf

Module 11_General Documentation Guidelines.pdf

Module 11_Improving Your Clinical Documentation Reflecting Best Practice.pdf

Assignments

- Complete Readings
- Post and reply in Discussion 11: Abbreviations
- Complete Assignment 2: Documentation
- Complete Assignment 3: SOAP Note
- Complete Quiz 11: Documentation