PlanĪ cohesive SOAP note will support your intention throughout your documentation, including your Plan for the patient. And that leads us to the final section of the SOAP note, the Plan. In this example, I address the patient’s limitations, offer an interpretation of whether or not the patient demonstrates an ability to improve, and provide a recommendation to help the patient achieve their goals. ![]() Continued progression of balance training and strengthening is required for safe handling of household items in overhead cabinets.” Repeated trials improved stability, but further training is recommended to improve safety while reaching overhead. ![]() “The patient was unable to perform reaching activities with a 1# weight without experiencing a loss of balance. Here’s an example of an assessment statement that supports the skill of a therapist billing for a unit of therapeutic activity: Example of Therapeutic Activity 97530 Assessment Statement Your assessment should address all these things-not just the treatments that were done, but how they were done, why they were done, and what your takeaway is as a licensed therapist. How does their ability to perform the activities in the clinic translate into their ability to do so safely and independently at home or in the community? They could have just followed a balance training video on youtube, so why did they come into the clinic? What did you add?Ĭonsider: Did you provide any cues? Did you direct or correct their movement? Did you notice any limitations or even improvements as they performed each task?Īnd then reflect on what their performance means for their recovery. This is where your therapy education truly shines.Īs you write your assessment, reflect on why YOU-a skilled therapist-are required to be there during that patient’s session. ![]() Think about the assessment section as the “why” behind your treatment. Although you can support that intent in your subjective statement and objective findings, you can express it even better in the assessment section. Remember, you’re shaping your treatment around improving functional performance, the definition of therapeutic activity. In the objective note, you may include something like this: “ The patient was unable to perform reaching activities with a 1# weight without experiencing a loss of balance.” That -ing word, “reaching,” will be the common thread throughout your note, linking your patient’s everyday limitation with the clinical movements and exercises you’ll use to assess and treat their balance. You just have to choose specific words in your documentation to keep the focus on the functional limitation your patient mentioned earlier.įor example, let’s say your patient identified “reaching into the cabinet” as something they have difficulty doing without losing balance (from your subjective section). However, you can still use the objective note to support your use of a therapeutic activity code. The objective section of your SOAP note describes the exercises and stretches you used to measure your patient’s limitations, including specifics such as weight lifted, range of motion achieved, or balance statistics. Not only will this pretty much cover my subjective notes, but it will also help me justify why I’ll be working on specific tasks recorded in my objective section. Meanwhile, I quickly write their answer down. ?”Īnd they usually mention actions such as “stepping up and down the stairs” or “squatting into a chair.” For example, at the beginning of each session, I always ask my patient “What things are still too difficult for you to do because of your shoulder, back, knee issue, etc. ![]() With the right prompting, your subjective note can almost write itself. Let’s look at each of these components one by one. There are four components to a SOAP note, and that means there are four opportunities for you to support your billing code with clear, descriptive documentation. How to Use Therapeutic Activity 97530 in your SOAP note
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