In the physical therapy objective soap note, should I provide the rational for each intervention done?

Answer 1

Well let's see. Ya got four choices:

Subjective
Objective
Assessment
Plan

Seems like your rationale for any intervention amounts to a combination of A and P, so yeah, write it down! But remember to read what you wrote, cuz if it makes no sense to you, it may not make sense to anyone else either.

Answer 2

This is usually not necessary since after your initial evaluation, you should have formed a problem list under "assessment" and a treatment plan under "plan"...therefore, everything you do at subsequent visits should be consistent with that initial plan. If, however, you discovered something new, or there was a change in status which required a change in the plan you should document that new treatment, and provide a rationale in the assessment.

Here is an example. A patient who was diagnosed by the doctor as having lumbar stenosis was evaluated in PT and appeared to present consistent with the diagnosis...pain with walking, releived with sitting, feels better with flexion of the lumbar spine. Your assessment should denote improvement with Williams flexion protocol. However, at a subsequent visit, the patient reports that his pain is now constant and radiates to the right foot. You find that the exercises make the patient progressively worse. Upon having the patient lie prone, it is discovered that his pain centalizes and gets better with repeated prone press ups. He remains better upon standing. You document what was done under "objective" and the responses to treatment, but under "assessment" you note that the impression is now of derrangement sysndrome. Under "plan" you denote the plan to change the HEP to repeated extension and discontinuation of the William's exercises. Your subsequent visits should now be rationalized for this new plan. If another PT goes to treat the patient, they will know to proceed with extension unless there is another change in status.

Answer 3

Well here's my two cents. I work for 2 orthopaedic surgeons and their PA's. They wrote the order to send the patient to PT and they decided which little boxes to check on our order sheet, so I'm pretty sure that they know what the rational for each intervention is. All that they are looking at when we get a PT report back for a pt f/u visit is:

1.) did they attend and did they attend as ordered.(compliance)
2.) Starting numbers an ending numbers to compare for progress, things such as flexion, extension, pain level, if pt feels PT is helping.
3.) Therapist recommendation for continued therapy or if therapist feels pt has progressed as much as possible.

Answer 4

This is just as insane as when you asked this yesterday.