I just spent eight hours traveling to beautiful Charlotte North Carolina to participate in Functional Pathways 360 CEU Symposium event!  While driving, I spent a lot of time thinking of the conversations I have had this week with therapists and assistants, with Regional Managers, and with Clinical Managers.  I thoroughly enjoy working with my colleagues on improving our coding skills and documentation skills to reflect all of the elite patient care we provide.

As I was driving down Route 77 south, I looked at the Blue Ridge Mountains off in the  distance and thought to myself, “they really do look blue!”  But are they really blue?  What they look like may not actually be what color they really are……that lead me to our residents and patients we treat….then that led me to documentation.

See, when a reviewer reads our therapy documentation, they see the resident/patient for what they look like in the distance, just like I saw the Blue Ridge Mountains.  But are they seeing the resident/patient actually as they are?  Are we as therapists and assistants portraying the functional status and skilled therapeutic interventions effectively in our documentation to provide the reviewer with the real picture?

We talk about things like ‘medical necessity’, ‘skilled intervention’, ‘sophistication of the documentation’, ‘reasonable and necessary’.  We talk about these terms so much that maybe it doesn’t even strike a nerve with therapists and assistants.  Unfortunately, these terms are extremely important and require intense concentration and attention by therapy clinicians.

I know I must sound like a broken record (“oh, there she goes again talking about documentation…”) but I have learned that if something is “in your face” often, you will pay attention to it….right?

If you don’t know how to ‘paint the picture’ when writing daily and weekly progress notes, go back to what you learned in school–therapy school that is!  Most of us learned S.O.A.P note writing, didn’t we?  Well, I know that I did even though it was 20 years ago!  When I have writers block, I revert back to S.O.A.P note writing to help me portray the resident’s/patient’s actual picture of where they are functionally and what I did that was skilled to improve their function and/or reduce their risk.

I am not going to bore you with a S.O.A.P note lesson but I would like to generally review.  Social Workers and other health care providers who struggle with documentation (“I don’t know what to write!!”) or get “stuck” sometimes can benefit from S.O.A.P note writing.

What does S.O.A.P stand for?  S=Subjective, O=Objective, A=Assessment, P=Plan.

S: This is subjective information provided by the resident/patient as it relates to therapy.  This can be the resident’s/patient’s opinion about his/her status including activities he/she is having problems with, the progress he/she has made, etc.

O: This is objective information by the therapist/assistant as it relates to resident/patient function.  Observe and measure the resident’s/patient’s strength, balance, bathing, dressing, range of motion, communication, swallowing, etc. Note whether each of these points have improved or worsened since the last session/last progress note.  This is the area where you compare prior status and underlying impairments to the current status and underlying impairments

A: This is where you document your professional opinion!  And yes, assistants, you DO have a professional opinion! Resident’s/patient’s compliance with the treatment program, provide your opinion of the resident’s/patient’s status, and your opinion of the improvement or worsening of the resident’s/patient’s ability to function

P: This is the therapist’s/assistant’s plan for continuing treatment.  Include any changes in the amount or variety of exercises, change/progression of assistive device, trials of a diet upgrade, use of adaptive equipment, trial of stair management, etc.  Don’t document, “Continue with POC”—that is a given.  Tell the reader what you plan to do within the next week of therapy—provide specifics.  If you called off sick, then the therapist/assistant will know exactly what you were wanting to accomplish

 Challenge yourself to improve documentation!—-Start Today!  This would be a great Self-Improvement task because you have a Responsibility to provide a clear and precise picture of the care you are providing as well as the resident’s/patient’s status which will help with colleague and client Relationships if they need to provide treatment in your absence or have an important conversation with a family member.

Even though the Blue Ridge Mountains are a beautiful misrepresentation of what they actually are, I don’t want our resident/patient care to be misrepresented!

Gina Henthorne, LPTA, RAC-CT

Director of Compliance