DOCUMENTATION :

All patients / clients who come into contact with a healthcare professional will have
details of that contact documented in their clinical record (also called the medical
record). These details are usually in the form of notes on the assessment, treatment,
progress and ultimate plan for the patient and can be summarized in the SOAP format.
Patient identification in the form of name, date of birth (DOB) and folder number on
every sheet in the record is vital, as well as numbering each page consecutively.
Note: There is an important distinction to make between the information in the clinical
record and the material on which it is stored. It implies that the information contained in
the record belongs to the patient, but the paper it's written on belongs to the hospital or
health professional. Thus, patients may take photocopies of the clinical record when
they are discharged, but not the record itself.
Documentation should be clear and accurate for the following reasons:
1. It promotes optimum patient care by providing a record of the baseline condition,
treatments and progress.
2. It ensures continuity of care.
3. It allows communication between members of the Multidisciplinary team (MDT).
4. It is a legal document that is admissible as evidence in court.
5. It provides evidence of the care provided and decisions made.
6. If you make a mistake during the documentation process, draw a line through the
incorrect entry and initial or sign it (some institutions require dating it as well).
Never use Tippex to obliterate an entry.
7. Abbreviations should be kept to a minimum, should only be used in the context of
care and must only refer to the diagnosis, treatment and interventions carried
out. They must be agreed and approved locally and therefore should not be used
in transfer or discharge documentation.
8. If it's not documented, it didn't happen!
What constitutes a clinical record?
 Paper records including books, files, letters, loose papers, continuation sheets
(or SOAP notes), diaries, post-it notes and computer printouts.
 Electromagnetic records including discs, servers and databases.
 Audio-visual records including films, tapes, videos and CDs.
 Photographs, maps, plans, X-Rays, microfiche and microfilms.
Principles of good documentation
 Write in chronological order.
 Record only factual information, not your opinion.
 Write legibly, printing if necessary.
 Use black pen, or print in black if the record is digital.
 Put patient quotes in quotation marks.
  Date all entries.
 Time all entries using the 24 hour clock (i.e. 18:00, not 6:00).
 Chart every intervention as soon as possible after the event.
 Chart notes should be neat and tidy.
 Sign each entry with a signature and position / role (e.g. Senior physiotherapist)
 Give the full name and title of all personnel mentioned in the record.
 Use only official Outcome Measures
 Test results must be signed and fixed to the proper mount sheet in the correct
date order.
Digital medical records
The Electronic Health Record (EHR) and Electronic Medical Record (EMR) are
standards that govern the technical specifications of how a patient's health information
will be stored as the health industry moves increasingly into a digital environment.

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.
They are entered in the patients’ 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 is an acronym for:
Subjective - What the patient says about the problem / intervention.
Objective - The therapist’s objective observations and treatment interventions (e.g.
ROM, Outcome Measures)
Assessment - The therapist’s analysis of the various components of the assessment.
Plan - How the treatment will be developed to the reach the goals or objectives.
Advantages and Disadvantages
Quinn and Gordon (2003) suggest that the major advantage of the SOAP documentation format
is it's widespread adoption, leading to general familiarity with the concept within the field of
healthcare. It also emphasises clear and well-organised documentation of findings with a natural
progression from collection of relevant information to the assessment to the plan on how to
proceed.
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. Delitto and Snyder-Mackler (1995) have also suggested that a sequential, rather than
integrative approach to clinical reasoning is encouraged, as there is tendency by the health
professional to merely collect information and not assess it[3]. They feel that the emphasis on the
problem-orientated approach to documentation is misplaced and that it is not conducive to
clinical decision-making.
One major difficulty with SOAP notes for physiotherapists, is the lack of guidance on how to
address functional outcomes or goals. Having said that, the format is not so rigid that it cannot be
adapted to take this into account.
Writing a SOAP Note
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. 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. However, the American Physical Therapy Association does provide the following
guidance on what information should be included:
1. Self-report of the patient
2. Details of the specific intervention provided
3. Equipment used
4. Changes in patient status
5. Complications or adverse reactions
6. Factors that change the intervention
7. Progression towards stated goals
8. Communication with other providers of care, the patient and their family
Bear 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. Therefore, it is your professional
responsibility to make sure that it is well-written.
Components of a SOAP Note
Subjective
This component is in a detailed, narrative format and describes the patients self-report of their
current status in terms of their function, disability, symptoms and history. It may also include
information from the family or caregivers and if exact phrasing is used, should be enclosed in
quotation marks. It allows the therapist to document the patients perception of their condition as
it relates to their progress in rehabilitation, functional performance or quality of life.
Common errors:
Passing judgement on a patient e.g. "Patient is over-reacting again".
Documenting irrelevant information e.g. patient complaining about previous therapist.
Objective
This section outlines the objective results of the re-assessment, the progress towards functional
goals and the treatments performed. It should include details of the interventions, including
frequency, duration and equipment used. The therapist should indicate changes in the patient's
status, as well as communication with colleagues, family or carers.
Common errors:
Scant detail is provided.
Global summary of an intervention e.g. "ROM exercises given".
Assessment
This is potentially the most important legal note because this is the therapists professional
opinion in light of the subjective and objective findings. It should explain the reasoning behind
the decisions taken and clarify and support the analytical thinking behind the problem-solving
process. Progress towards the stated goals are indicated, as well as any factors affecting it that
may require modification of the frequency, duration or intervention itself. Adverse, as well as
positive responses should be documented.
Common errors:
The assessment is too vague e.g. "Patient is improving".
Little insight is provided.
Plan
The final component of the note is used to outline the plan for future sessions. The therapist
should report on what the patient's Home exercise programme (HEP) will consist of, as well as
the steps to take in order to reach the functional goals. Changes to the intervention strategy are
documented in this section.
Common errors:
The upcoming plan is not indicated.
Vague description of the plan e.g. "Continue treatment".

Example of a SOAP Note

Current condition: COPD/pneumonia
Goals 1. Pt. will demonstrate productive cough in seated position, 3/4 trials. 2. Pt. will ambulate
150ft with supervision, no assistive device, on level indoor surfaces.
S: Pt. reports not feeling well today, "I'm very tired".
O: Auscultation findings: scattered rhonchi all lung fields. Chest PT was performed in sitting
(ant. and post.). Techniques included percussion, vibration, and shaking. Pt. performed a weak
combined abdominal and upper costal cough that was nonbronchospastic, congested, and non-
productive. The cough/huff was performed with VC. Pectoral stretch/thoracic cage mobilizations
performed in seated position. Pt. given towel roll placed in back of seat to open up ant. Chest
wall. Strengthening exercises in standing - pt. performed hip flexion, extension, and abduction;
knee flexion 10 reps x 1 set B. Pt. performs HEP with supervision (in evenings with wife). Pt.
instructed to hold tissue over trach when speaking to prevent infection and explained importance
of drinking enough water.
A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been
compliant with evening exercise program, which has results in increased tol to therapeutic
exercise regime and an increase in LE strength. Amb. not attempted to 20 to pt. report of fatigue.
Pt. should be able to tolerate short distance ambulation within the next few days.
P: Cont. current exercise plan including CPT; emphasize productive coughing techniques;
increase strengthening exer reps to 15; attempt amb. again tomorrow.