Senin, 02 Februari 2009

The Audacity of SOAP

SOAP notes hinder good physical therapy documentation.

SOAP notes began in the 1950's as part of the Problem Oriented Medical Record (POMR) for physician decision-making.

SOAP has been implicated by many authorities as hazardous to physical therapist decision-making.

Imagine this scenario: 

A big, fat hospital chart with specialty information: 

  • internal medicine
  • orthopedics
  • cardiology
  • gasteroenterology
  • physical therapy
...all represented in one chart.

Clipped to the front of the chart is a single sheet of paper with the (in)famous acronym: S.O.A.P.

The doctor, whatever her specialty, needs to see the patient and do the following:
  • establish the reason for the visit (S)
  • take measurements (O)
  • arrive at a medical diagnosis (A) and
  • establish the plan of care (P)
Do physical therapists need to make these decisions - each visit?

*****

Do physical therapists make the same decisions as medical doctors?

SOAP hinders physical therapy notes because physical therapists make different decisions than medical doctors.

Daily, physical therapists need to assess and measure patients' activity and participation levels and make decisions based on the measurements.

For example...
"Today, I can't walk as far as yesterday because the bad weather has swollen my knee and hip joints"
Because her medical diagnosis is chronic knee osteoarthritis you decide to measure her knees and you find increased swelling, due to the weather.

You decide to alter her plan of care - instead of exercise today you want to use modalities.

You decide to recommend a cane, during the period the knees are swollen - to prevent falls.

Will your SOAP note support your decision-making?

Many authorities don't think so.

Is it time to ditch SOAP?

Do physical therapists need a proprietary clinical note-writing format?

The Audacity of SOAP Rating: 4.5 Diposkan Oleh: Elvina dara

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