Our tips on this tried-and-true formula for reducing the rate of billing errors at your practice.
Proper medical documentation requires dedicated time and knowledge, creating a serious pain point for busy physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs). It takes practice to correctly document each patient appointment quickly while remaining compliant with payer requirements.
But without detailed notes, providers risk billing errors, delays, and denied reimbursements. In turn, profit margins are impacted, and the high demand and lack of time have the potential to lead to provider burnout as they struggle to meet documentation requirements of Medicare and private insurance companies.
You probably already know that relying on the SOAP format can help alleviate the stress of proper billing and coding. After all, it’s been the standard for compliant patient documentation for more than 70 years.
Even though you know how to use SOAP, brushing up on your technique can help you save time on documentation without compromising defensible claims for outpatient rehabilitation services. With this guide, learn how to use SOAP to your advantage for SLP, OT, or PT practice billing with tips, tricks, and smart strategies for success.
The top priority: Defensible Documentation
SOAP is the primary documentation method of health care providers, including physicians, nurses, and rehabilitation therapists.
While most payers accept SOAP as an appropriate documentation format for insurance claims, defensible documentation must go beyond the basics of subjective, objective, assessment, and plan. SOAP notes are designed to be short and factual, so they are easy for other providers to read and interpret, which also improves the continuity of care for patients.
However, many providers struggle to balance concise simplicity with the detail required for defensible claims. Reviewing SOAP note examples can help you become more familiar with this widespread format and how to perfect it for yourself.
But what SOAP really relies on in an outpatient rehab therapy setting is documenting defensibly. Defensible documentation provides proof of medical necessity if an insurance audit arises. Most payers also require this proof for SLP, OT, and PT services before reimbursing claims.
To meet the expected standards of proof, make sure all SOAP notes are standardized for your practice and match others in your specialty. Notes should be clear, concise, non-judgmental, and focused entirely on the patient and their care plan.
The fundamentals of medical documentation
When done correctly, solid medical documentation can help providers receive reimbursement more quickly, provide protection from legal liability, and create an understandable reference for physicians and other care providers who may also treat your patients. As SOAP has been in use for over 70 years, providers have found sound documentation often meets four principles:
- It illustrates a clear, thoughtful process for patient assessment and care.
- It demonstrates use of sound clinical judgment.
- It shows the patient’s capacity to participate in care planning and decision-making.
- It adheres to payer guidelines with inclusion of treatment goals, diagnosis, types of services, and frequency and duration of treatment sessions.
Remember that taking good notes does not necessarily mean writing longer notes. Instead, focus on communicating the necessary information as concisely as possible.
Our six tricks to improve your SOAP notes
If you’re new to the SOAP format, strategic notetaking can feel unnatural at first. Enhance defensibility and clarity of patient documentation with these valuable SOAP note tips:
- Use Templates: Use EMR-based templates rather than writing brand-new notes for each new patient. For example, Clinicient’s EMR, the Insight Platform, allows providers to choose between narrative note templates and those that require them to complete a fill-in-the-blank form. The use of templates creates a consistency that improves organization and readability, reduces costly errors, and saves valuable provider time.
- Be Mobile: Document at the point of care with your tablet or smartphone to avoid missing important details. That way if you’re performing exercises with your patient, you can still notate your observations, assessments, and treatment goals quickly. Mobile tools like voice-to-text can make your documentation even faster.
- Write Reminders: If you can’t complete the patient’s documentation during their visit, keep short reminder notes to help you recall details for later. Write down numbers, facts, and other items you might not recall precisely after the session.
- Create SMART Goals: Use the SMART method to set goals (specific, measurable, achievable, relevant, and time-bound). This framework provides a way for the patient and therapy team to track progress objectively and collaboratively.
- Use Active Voice: Use action words like observed, established, coached, adapted, assessed, or evaluated. This helps you keep notes in active voice rather than passive voice for better clarity and readability.
- Write For Relevance: Leave out details that do not support the medical necessity of the patient’s treatment plan. If you aren’t sure, ask yourself whether the payer will find the information you shared is relevant to approving the claim. Will it impact the defensibility of your notes? Can payers get a full scope of the processes performed during the patient visit? Be critical, and don’t be afraid to trim unnecessary information.
SOAP note example for occupational therapy
For our occupational therapy example, we’ll be documenting a patient visit whose goals include developing and using a functional grip with writing tools, as well as crossing the midline when engaging in these activities.
Subjective: Document the patient’s report of their injury or condition, as well as their caregiver’s report, if applicable.
The patient entered the appointment room and said he is very tired today. His parent said he uses his right hand about two-thirds of the time and switches to the left hand the other third.
Objective: In this section, write what you observe during the session with the patient.
The patient used a violin grasp in about 20 percent of writing opportunities during the session and a digital pronate grip during the other 80 percent of opportunities. He tends to switch to the left hand when the utensil has been placed on the left. Patient uses the elbow and shoulder to generate coloring movement. He used his hands for neck support with elbows propped on the table and fell out of his chair twice. He required verbal prompts to cross the midline in 50 percent of exercises.
Assessment: In this section, you note your evaluation of the patient’s progress.
The patient still displays emerging hand dominance. He lacks postural control and proximal stability because of challenges with the small hand muscle isolation necessary for functional grasp.
Plan: In this section, document the next steps for your patient based on the assessment.
Support teachers and caregivers with midline crossing resources and activities. Continue 60 mins OT 1x/week to work on grasp and midline crossing. Possible referral to PT for postural control issues, continue to monitor. Offer short writing utensils to help support development of grasp.
SOAP note example for physical therapy
In this SOAP note example for physical therapy, we look at documentation for a male patient in his 60s referred with knee pain.
Subjective: Document the patient’s report of their injury or condition, as well as their caregiver’s report, if applicable.
The patient said he has had left knee pain for about five years before first seeking treatment in late 2020. He was diagnosed with arthritis and had total knee replacement in May 2021. His recovery went smoothly, and he wants to regain mobility and function.
Objective: In this section, write what you observe during the session with the patient.
Patient uses a walker and favors his left knee. He describes increased pain when flexing the knee as well as along the incision, which is healing well and has no open areas. Lower extremity functional outcome score revealed disability of 55 percent.
Assessment: In this section, you note your evaluation of the patient’s progress.
Patient problems include impaired gait, limited home exercise, impacted posture, inability to bear weight on the knee, diminished balance, strength, and range of motion in the knee, and increased pain in the knee.
Plan: In this section, document the next steps for your patient based on the assessment.
Patient should continue 2x weekly PT appointments for six weeks and receive reassessment for progress after six to eight visits. Treatments will include strengthening exercises, balance training, posture and body mechanics training, ice application, and neuromuscular exercises.
SOAP note example for speech therapy
If you’re wondering how to write better SOAP notes for speech therapy, study this example of a woman in her 80s struggling with language issues after having a stroke.
Subjective: Document the patient’s report of their injury or condition, as well as their caregiver’s report, if applicable.
Although the patient was tired after being awakened from her nap, she quickly became alert and participated throughout the session. She expressed a positive attitude about therapy and feels pleased with the progress she has made in language.
Objective: In this section, write what you observe during the session with the patient.
The patient displayed eight instances of paraphasia during the session and acknowledged the errors about 75 percent of the time. She also had six instances of anomia and was able to find the misplaced word about 50 percent of the time.
Assessment: In this section, you note your evaluation of the patient’s progress.
The patient is making progress with her language goals, as evidenced by the ability to recognize anomia and paraphasia. Over time, she will be able to adjust to these challenges and recall more words. She also benefits from significant family support.
Plan: In this section, document the next steps for your patient based on the assessment.
The next session will involve the patient’s family as we work to transition her out of speech-language therapy. The team will continue to provide encouragement and cues as needed, in addition to assisting the family and patient with strategies and resources.
Improve documentation compliance and speed with the right EMR for your clinic
While clinical documentation challenges providers across the medical spectrum, practice makes perfect when it comes to taking defensible notes and reducing the rate of rejected claims.
If your clinic is looking for a simple EMR with customizable documentation templates, a mobile-friendly interface, and built-in billing automation, connect with our team to hear more about our Insight Platform. Schedule a free, no-obligation demo today.
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