BOOK EXCERPT
Documentation Basics: A Guide for the Physical Therapist Assistant
Mia Erickson EdD, MS, PT, ATC; Becky McKnight MS, PT

Chapter 3
Documentation Formats
Mia L. Erickson, PT, EdD, ATC, CHT

Chapter Objectives

After reading this chapter, the student will be able to:

1. List 4 types of documentation formats used in physical therapy.
2. Examine different types of physical therapy documentation formats.
3. Describe each type of documentation.
4. Explain advantages and disadvantages of different documentation formats including narrative and SOAP notes, problem-oriented medical records (POMR), and functional outcomes reporting (FOR).
5. Differentiate between information found in the S, O, A, and P portions of a SOAP note.
6. Identify positive and negative aspects of using forms and templates.
7. Examine positive and negative aspects of computerized documentation.
8. Documentation in physical therapy practice can take on a variety of formats depending on the type of patients being treated, practice setting, state laws and practice acts, and reimbursement requirements. Different documentation formats include: narrative reports, problem-oriented medical records (POMR), SOAP, and functional outcomes reporting (FOR) (Figure 3-1). A brief discussion of each of these formats is provided in this chapter.

Documentation in physical therapy practice can take on a variety of formats depending on the type of patients being treated, practice setting, state laws and practice acts, and reimbursement requirements. Different documentation formats include: narrative reports, problem-oriented medical records (POMR), SOAP, and functional outcomes reporting (FOR) (Figure 3-1). A brief discussion of each of these formats is provided in this chapter.

Narrative

In narrative documentation, the clinician describes the patient encounter. This type of documentation provides pertinent information written mainly in paragraph format. There may or may not be headings identifying important information. Headings used in narrative notes are at the discretion of the clinician writing the note. When using the narrative format, Quinn and Gordon³ recommend that you develop an outline of information to cover so that important details are not omitted.

Narrative Example:
Date: 3/3/04
Patient: John Smith
Pt. RTC reporting no adverse effects from tx last visit or from HEP. He stated that he feels as though his wrist & ankle are moving a little better and the edema in the hand has . He reports that he is able to shower (I) using a plastic chair in the tub and feels like he has improved c his ability to dress himself. AROM of the (L) wrist is as follows: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, and pronation 60°; (L) knee: 0-135°; (L) ankle DF-PF 5-45°. Figure 8 wrist girth is 35.5 cm and ankle figure 8 girth is 43 cm on the (L). Pt. is ambulating household distances (I) c cx using (L) UE platform, PWB 50% on the (L) LE. (I) with all transfers and self-care. Tx consisted of gentle AROM and PROM for 30’ to the (L) wrist and forearm in the directions of flexion, extension, supination, & pronation, and to the (L) ankle for DF, PF, inv, & ev. Pt. also performed AROM for the hand. The pt. has made improvements in AROM and has edema. Improvements have allowed pt. to improve his ability to ambulate (I) and perform self-care. Will continue to have the pt. perform his HEP and RTC on 3/5/04.

Bill Jones, PTA

There are times when the narrative format is the most appropriate format to use. These include describing a sequence of events, brief interactions with patients, conversations with other health care providers, or any other situation that requires a detailed explanation and none of the other documentation formats are appropriate. In these instances, you can simply describe the situation and how it affects the patient in a brief narrative note. Narrative notes are sometimes the easiest to use when you just need to describe the details of a situation and you are trying to paint a vivid description of what happened.

Example:
Date: 6/18/03
Patient: John Smith
Spoke with patient’s physician today regarding the amount of weight bearing he is allowed to perform when ambulating with the platform cx. He stated that his fx sites on the radius and ulna are stable and healing well, and he can WBAT on the UE. Will have patient continue to use crutches with platform on the (L), allowing him to weight bear through the extremity as indicated by the physician.

Authors have identified several problems with the narrative record. First, due to the lack of structure, the writer is prone to omit details that could potentially be very important. In addition, there is a high degree of variability among clinicians.³ When medical notes are lacking structure, it might be very difficult to read and locate necessary information. For example, it would be very time consuming for a case manager to sort through a chart filled with unstructured narrative entries to locate information regarding the patient’s ability to transfer. Furthermore, following the clinician’s problem-solving process can be difficult in narrative reports.²⁴ For these reasons, more structured documentation formats have emerged.

Problem-Oriented Medical Record

The problem-oriented medical record (POMR) was introduced by Lawrence Weed to provide medical students with a structured documentation format oriented around the patient’s problems.²⁴ He believed that the narrative format was often confusing and unorganized, making it difficult to determine how the physician defined and treated various patient problems.²⁴ In the POMR, the first page consists of a patient-problem list. This serves as the “Table of Contents” for the remainder of the medical record.

Example:

Problem #1:	A/PROM left wrist
Problem #2:	A/PROM left ankle
Problem #3:	strength left wrist
Problem #4:	strength left ankle
Problem #5:	(I) c ambulation

Subsequent entries, or progress notes, are organized according to these problems. For each entry, the physician discusses management of each problem in the following terms:

• Subjective Data: This includes symptomatic data provided by the patient.
• Objective Data: Identifies results of tests and measurements performed or physical exam data.
• Impression (Imp.): The practitioner’s impression of the patient and that particular problem.
• Treatment and Therapy (Rx): Treatment or therapy provided for that particular problem on that day or during that session.
• Immediate Plans (Plan): Treatment plan for that particular problem.

Example:
Problem #1: A/PROM left wrist
Subj: Pt. reports no adverse effects from last treatment; States that the wrist and hand are moving better allowing him improved functional activities
Obj: AROM (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, and pronation 60°
Imp: A/PROM improving with exercise; improvements allowing more functional use of the wrist and hand
Rx: 2 x 10 reps AROM and PROM for flexion, extension, supination, and pronation
Plan: Have pt. continue c HEP and RTC in 2 days

Using this format, the reader can identify the patient’s care for each of the identified problems.

Major advantages of POMR include:^11-13,25,26

1. Provides organization and structure to the medical information.
2. Includes a comprehensive list of the patient’s problems.
3. Discusses each of the patient’s problems separately.
4. Provides a specific plan for managing each of the patient’s problems (ie, treatment is problem-oriented).
5. Allows a physician who is interested in a particular problem to go directly to that aspect of the note, thus improving communication among care providers.
6. Provides a chronological sequence of interventions for a particular problem, better outlining the problem-solving process.

Regardless of the benefits to the structure provided with the POMR, authors have reported problems with it as well. First, the POMR separates, or fragments, patients according to their problems, and this might pose a problem in complex cases if a provider doesn’t see the “whole patient.”²⁵ In the case of John Smith, it is possible that a therapist working with the upper extremity might not be aware of the lower extremity problems without reading separate chart entries. This could be very time consuming. In addition, for patients with multiple problems, the POMR can become increasingly complex, requiring an extraordinary amount of time for an individual managing multiple problems. In our example, the patient has many problems, and for one therapist, this could result in as many as 5 to 6 different chart entries per visit. Therefore, it is not suitable for more complex rehabilitation patients.¹¹

SOAP Notes

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. SOAP evolved from the POMR documentation format initially provided by Weed as described in the preceding section. Like with the POMR, “S,” or subjective, should include anything the patient tells you pertaining to his or her injuries or problems. Subjective information can also be any information provided by the patient’s family or caregivers. The “O,” or objective, section should include relevant tests and measurements performed, the patient’s functional status, and physical therapy interventions performed for that day of service. Unlike the POMR, in the SOAP format, the physical therapy interventions are written in the objective portion of the note. The interpretation, or impression, has been designated “A,” for assessment. In SOAP format, the “P” stands for plan. More detailed examples of information provided in the S, O, A, and P portions of the notes can be found in Figures 3-2 through 3-5.

Unlike the POMR, one SOAP note generally includes information pertaining to all of the patient’s problems. However, the SOAP note may or may not be preceded by a problem (“Pr”) section. When it is, the “Pr” section contains information pertaining to the medical diagnosis and/or referral information (example below). You will read more about the SOAP sections, including the problem section, in Chapter 4.

The SOAP format is now widely used by a variety of medical and rehabilitation professionals, although it is no longer associated with the POMR.³ SOAP has become a stand-alone format for documentation. Like the POMR, SOAP note documentation provides structure to medical record entries and should be used to show logical decision-making by using subjective and objective information to determine an assessment and plan.

SOAP Example:

(Please note: This is the same information that was provided in the narrative and POMR notes above. Pay particular attention to the organization of subjective and objective information as well as the assessment and plan under the appropriate headings):

Date: 3/3/04
Pr: 27 y.o. s/p (L) wrist and ankle fx; Begin gentle wrist and ankle AROM & PROM
S: Pt. RTC reporting no adverse effects from tx last visit or from HEP. He stated that his wrist & ankle are moving a little better and the edema in the hand has . He reports that he is able to shower (I) using a plastic chair in the tub and feels like he has improved c his ability to dress himself.
O: AROM (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, pronation 60°; (L) knee: 0-135°; (L) ankle DF-PF 5-45°. Girth: (L) wrist figure 8: 35.5 cm and (L) ankle figure 8: 43 cm. Tx: gentle AROM and PROM for 30’ to the (L) wrist & forearm for flexion, extension, supination, & pronation. Pt. also performed hand AROM.
A: The pt. has made improvements in AROM and has edema. Improvements have allowed pt. to improve ability to ambulate (I) and perform self-care.
P: Will continue to have the pt. perform his HEP and RTC on 3/5/04.

Bill Jones, PTA

Even though SOAP notes provide a consistent and concise format for documenting the patient’s subjective remarks, objective exam findings, the provider’s overall impression, and the plan of care, the documentation procedure has been scrutinized recently. Several reasons for this scrutiny exist. First, objective findings are often written in terms of impairments, such as range of motion, strength, balance, etc. Furthermore, links between improvements in the patient’s impairments and improved functional capabilities are usually implied, rather than described in detail.^27,28 This often results in documentation centered around the patient’s complaints and impairments, rather than documentation that focuses on progress and improving function. In addition, SOAP notes usually don’t show how the interventions are contributing to functional improvements. Nevertheless, the SOAP format is widely accepted and can be an appropriate form of documentation if its emphasis shifts toward linking impairment, function, and intervention.

Functional Outcomes Reporting (FOR)

Functional outcomes reporting (FOR) is becoming more popular in rehabilitation. Quinn and Gordon³ describe FOR as a type of documentation that focuses on the ability to perform meaningful functional activities rather than concentrating on isolated musculoskeletal, neuromuscular, cardiopulmonary, or integumentary impairments. Advantages of FOR have been identified. FOR establishes a relationship between the patient’s impairments and the ability to perform functional tasks, and it improves readability for non-health care providers reviewing documentation.^3,29

While the importance of FOR has been provided in preceding sections, SOAP format is still the most common type of documentation used in physical therapy practice. Authors have suggested combining FOR with the SOAP format.^29,30 When combining FOR with the SOAP format, Abeln²⁹ suggested making the following additions to SOAP:

1. Objective (O) Section: Clearly and objectively describe the patient’s functional status, including functional activities that are specific to that patient.
2. Assessment (A) Section: List only those impairments being addressed with therapy. Describe how improvement in impairments will lead to improvement in functional limitations. Provide complicating factors, ie, co-morbidities. PTs write goals using functional terminology.

Example (SOAP and FOR Combined):

(Please note: The following is the same example that was used to demonstrate narrative, POMR, and SOAP formats. This example combines the FOR with the SOAP format as recommended by Abeln.²⁹ Additions are presented in italics.)

Date: 3/3/04
S: Pt. RTC reporting no adverse effects from tx last visit or from HEP. He stated that his wrist & ankle are moving a little better and the edema in the hand has . He reports that he is able to shower (I) using a plastic chair in the tub and feels like he has improved c his ability to dress himself.
O: AROM (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, pronation 60°; (L) knee: 0-135°; (L) ankle DF-PF 5-45°. Girth: (L) wrist figure 8: 35.5 cm and (L) ankle figure 8: 43 cm. Functional Status: Gait: Ambulates household distances with (B) axillary cx c (L) UE platform, PWB 50% (L), (I). Transfers: (I) c all transfers Self-care: (I) c showering and dressing. IADLs: Unable to work; Unable to assist wife c child care duties. Tx: gentle AROM and PROM for 30’ to the (L) wrist & forearm for flexion, extension, supination, & pronation. Pt. also performed hand AROM.
A: The pt. has made improvements in AROM and has edema, although both remain to be impairments. Decreased edema and exercise have improved AROM allowing improved use of wrist & hand during self-care and use of ankle for normal gait pattern. Continues to require use of cx 2° to PWB status—this is limiting his ability to ambulate s an AD.
P: Will continue to have the pt. perform his HEP and RTC on 3/5/04.

Bill Jones, PTA

This chapter outlines several different types of physical therapy notes, each being used to document patient care. These included the narrative note, POMR, SOAP notes, and FOR. In hospitals and clinical settings, you are likely to encounter a wide variety of documentation formats, and it is important that you adhere to both state and federal laws as well as your facility’s approved format. It is the author’s experience that the POMR is least prevalent while the SOAP format is most widely used; however, FOR is becoming increasingly more popular. Narrative notes also serve distinct purposes as previously described. Although there is no documented evidence suggesting superiority of one type of note over another, you will soon find that in real-world clinical practice, you are likely to apply principles from the 3 latter types, thus using a combination of narrative, SOAP, and FOR. The authors of this text have selected the SOAP format to provide a framework for basic documentation skills. This format was selected because of its prevalence in clinical practice and because of its adaptability to a variety of documentation styles, thus meeting the needs of your employer and payer sources, and complying with the law. In this text, you will learn to use SOAP as the basic structure for your notes. However, additional emphasis will be placed on documenting the patient’s functional status; linking impairments, functional limitations, and interventions; linking interventions with improvement; and referring to the initial evaluative note for making clinical decisions.

Templates and Fill-in Forms

In order to facilitate documentation and eliminate time constraints, clinicians have started using a variety of documentation templates and fill-in forms. Forms can be either paper or computer-based. These forms not only save time but have potential to minimize writing, improve accuracy and consistency across patients, prompt clinicians to provide more data,³¹ and include essential documentation requirements set forth by Medicare or other third-party payers.³² Initial evaluations, progress notes, reevaluations, discharge summaries, and physician progress updates are often written using standard forms developed by individual facilities. Several paper examples of standardized forms and templates have been provided in Appendix B. The Guide to Physical Therapy Practice also includes documentation templates for both inpatient and outpatient physical therapy.⁷

Forms and templates can also provide a mechanism for multidisciplinary documentation in which each discipline has its own section to complete on the same form. For example, in inpatient rehabilitation settings and in skilled nursing facilities, Medicare payment is determined by data provided through multidisciplinary fill-in forms. Examples of multidisciplinary forms include the Minimum Data Set, used in skilled nursing facilities, and the Inpatient Rehabilitation Facility Patient Assessment Instrument, used in inpatient rehabilitation hospitals.

While fill-in forms and templates often ease time constraints and improve consistency, both PTs and PTAs must take care in not allowing the form to “dictate” the session. This is especially important for students and new graduates who may feel like they can not deviate from the form. In some instances, clinical instructors and employers will require students and new graduates to document using one of the above described formats (Narrative, SOAP, etc) rather than using the standard facility templates or fill-in forms. More importantly though, forms can promote incomplete documentation.^20,33 Providers must be sure that forms contain all essential information and have areas where you are able to add narrative comments.²⁰ These areas allow you to describe aspects of the patient’s care that are not part of the standard forms. Remember to document all relevant aspects of the patient’s care, including characteristics unique to some patients that might not be part of the standard forms or templates. Another problem with forms is that they are often geared toward the patient population treated most at the facility. It might be difficult to use these forms when documenting on patients with less common diagnoses.

Computerized Documentation

Computer-based documentation is one of the most rapidly growing areas for the use of computer technology in rehabilitation.³⁴ Computer-based documentation can range from basic word processing documents with fill-in form features to complex computerized documentation software packages. As with paper-based forms, initial examination/evaluations, progress notes, reevaluations, discharge summaries, and letters are common types of templates integrated into computer-based documentation packages. In some cases, documentation software is integrated with billing packages.

Benefits to computerized documentation packages include submitting information to payers electronically, building databases, tracking visits, and monitoring clinician productivity.³⁴ However, an important consideration of computerized documentation is the cost-benefit ratio. The benefits of using the software must offset its expense. In addition, staff training, technical support, rapid obsolescence of hardware and software, and upgrade costs are important considerations for implementing a computerized documentation system. Templates that accompany computer-based documentation packages must reflect the facility’s expertise and practice or be easily modified.³⁴ Furthermore, the clinic must be prepared for regularly scheduled system back-ups of main and individual computer terminals so that critical information is not lost. There must also be processes for storing system back-up files. Abeln³³ suggests storing back-ups away from the computer systems themselves. Finally, there must be a mechanism to record, give reason for, and authenticate late entries.³³

Types of computerized documentation packages include:

1. Clinicient (www.clinicient.net)
2. TurboPT (www.gssinc.com)
3. ReDoc (www.rehabdocumentation.com)
4. TalkNotes (www.provox.com) (Provox Technolo-gies Corporation, Roanoke, Va)
5. TherAssist (www.therassist.com)
6. QuickNotes (www.qnotes.com) (Quick Notes Inc, Cooper City, Fla)

Recently, the APTA and Cedaron Medical Incorporated joined forces to create APTA Connect, a computerized documentation package that will allow scheduling, documentation, outcomes tracking, and communication with other providers.³⁵ For more information on APTA Connect or Cedaron Medical Incorporated you can visit the following Web sites:

1. APTA: http://www.apta.org/PT_Practice/For_Clinicians/aptaconnect
2. Cedaron Medical Inc: http://cedaron.com/cedaron/aptaconnectdatasheet1.htm

An area of growing concern with computer-based documentation is patient confidentiality, especially when documentation software resides on a server or when health information will be transmitted electronically. The Health Insurance Portability and Accountability Act (HIPAA) provides federally regulated standards for handling individually identifiable health information during electronic transmission. HIPAA requires that facilities adopt privacy policies and procedures for maintaining secure patient records so they are not accessible to unauthorized personnel.³⁶

Review Questions

1. List 4 types of documentation formats used in physical therapy.

2. Describe similarities and differences between narrative notes, POMRs, SOAP notes, and FOR.

3. Describe advantages and disadvantages of narrative, SOAP, POMR, and FOR documentation.

4. What type of information is found in the S, O, A, and P portions of a SOAP note?

5. When using SOAP and POMR formats, where should you place information provided by the patient’s family?

6. What are positive and negative aspects of using forms and templates?

7. What are the positive and negative aspects of computerized documentation?

8. What is HIPAA? Investigate specific regulations regarding handling of individual’s medical records and protected health information.

9. Do you think general computer anxiety would hinder use of computerized documentation? Why or why not? What could clinics provide to their staffs to help reduce computer anxiety when implementing computerized documentation or when training new staff?

Application Exercises

1. Answer the following questions.

1. Research some of the computerized documentation packages listed in this chapter. What are the some of the associated benefits of using these as indicated by the company? What is the cost? What is the policy on technical support and upgrades? Do they appear to be “user-friendly?” Why or why not?

2. Research APTA Connect. What does it offer? What are some of the advantages and disadvantages of having standardized computer software across a variety of clinics?

3. Talk to (a) clinician(s) in your area about documentation formats used at their facilities. What do they like or dislike about documentation formats currently used? What other formats have they tried? What would be the ideal documentation format?

4. Your supervising PT has asked you to work with a patient with the following problems: flaccid left upper extremity, weakness in left lower extremity, dependence with ambulation, requires assist for all transfers, unable to perform self-care or home management skills.

• List 3 questions that you could ask this patient when initiating a treatment session to elicit informa- tion for the subjective portion of a SOAP note.
• What are 3 tests, measurements, or functional activities you should document on this patient?
• Compare and contrast SOAP, POMR, and FOR for this patient. What would be the same in all 3? What would be different? Which of these documentation formats would be most difficult to complete for this patient?



2. Read each statements and determine if it would belong in the S, O, A, or P portion of a SOAP note.

1.	_____	Gait: Ambulated 50’ x 2 WBAT (R) LE c min @ x 1 and verbal cues to advance the (R) LE
2.	_____	Pt. reports that the HEP has helped improve ROM
3.	_____	Pt. will RTC 2x/wk for the next 4 wks
4.	_____	Transfers: bed chair c mod @ x 2
5.	_____	Pt. progressing toward goals set on the initial evaluation
6.	_____	Pt.’s wife stated that she has been assisting the pt. c his HEP
7.	_____	Speak c the PT about possible reeval. 2° to pt’s rapid progress
8.	_____	AROM: (R) knee 0-135°
9.	_____	Improvements in knee ROM allow pt. to sit s difficulty and stairs c less difficulty
10.	_____	Pt. feels that he is benefiting from the strengthening exercises in that he is now able to open jars and lids (I)
11.	_____	Pt. will be seen for bid gait training
12.	_____	Pt. c/o inability to move her (L) UE and LE
13.	_____	Pt. denies use of AD PTA
14.	_____	Gait distance improved from 25’ to 150’ over the last week
15.	_____
15.	_____	Pt. demonstrating (L) neglect making her unsafe during gait and transfers
16.	_____	Muscle Performance: All (R) LE strength is 5/5
17.	_____	Vitals: HR 95 bpm, RR 12, and BP 140/95
18.	_____	Pt. has improved ability to transfer in/out of bed since initial visit
19.	_____	Pt.’s endurance is poor 2° to COPD
20.	_____	C/O inability to brush teeth and eat c the (R) hand 2° AROM of the (R) elbow
21.	_____	Pt. is unable to drive or perform safe community mobility at this time
22.	_____	Edema in the (R) ankle has 2 cm.
23.	_____	Pt. dons/doffs prosthesis (I)
25.	_____	Wound appearance: 100% red, healthy granulation tissue c minimal drainage




3. Of the above statements, which would be considered “functional” and appropriate using FOR (Refer to p. 25 for suggestions when using FOR)?