Tips and Tricks: Creating SOAP Notes, Client Goals, and Tests

In our Tips and Tricks series, we will provide readers with novel ideas for making the most of Practice Perfect EMR in their clinic.  

 

Practice Perfect is used by many different therapists, from many different disciplines, on many different patients—but the one thing that they have in common is their need to document the patients’ progress in the form of daily progress notes, otherwise known as SOAP notes. Knowing this, Practice Perfect has designed a number of tools to assist with these tasks.

 

Writing SOAP Notes

 

Every therapist knows how important it is to complete their daily notes. And before EMR software came along, they’d spend countless hours writing their patients’ SOAP notes by hand—even if it just meant rehashing previously completed notes. But today this process has been simplified in a number of ways.

 

Practice Perfect gives users the ability to bring forward completed and signed progress notes. By doing this, they no longer have to type out their notes from scratch, and can modify values as needed. We also created a ‘paragraph builder’ which is capable of inserting complete, editable paragraphs with the click of a button.

 

Click here to watch our video about how to complete daily progress notes.

 

Updating Client Goals

 

Client goals represent the target that your patient is aiming for. Whether a car accident victim wants to regain motion of their right shoulder, or the parents of a young child with cerebral palsy want them to be able to sit upright on their own, there’s a goal that treatment is working towards.

 

Client goals are often included as part of the SOAP note. The SOAP note is intended to detail what took place during the therapy session, and that certainly involves the progress made towards the goal.

 

Do you want to skip to the part about entering client goals? Click here.

 

Administering Tests

 

Functional tests are a considerable part of most daily progress notes. Examples of which include the Oswestry Disability Index, a Stuttering Severity Scale, or the standard Sit and Reach Test. So, it shouldn’t come as a surprise that we include a special section especially for test results.

 

If you want to see exactly how to create SOAP notes, client goals, and tests, check out our tutorial video below: