Progress Notes
Probably one of the hardest things to learn as a therapist is writing progress notes. If you're involved in long term care, then you know these are a requirement from Medicare and insurance companies. Documentation of their patient's progress is normally required at specific time schedules.
SOAP notes were the first type of documentation mentioned in school. Soap notes, I thought? Do we need to document on how well the patient can wash? All kidding aside, we soon learned what SOAP stands for, which is Subjective, Objective, Assessment, and Plan. This has always helped me organize thoughts when I write notes, even when writing a narrative note. Currently my documentation is all VIA computer where I work. We use a program that prompts you for all the basic patient information, and then has a small area for writing a narrative note underneath. This is a big help to stay current on notes.
So we all know that notes are due weekly on your Part A Medicare patient, daily (or with each visit) on the Part B Medicare patient, and at various times by insurance companies for their patients. Sometimes notes can seem to come due quickly, and many times when I see a patient with a note due that day think "Didn't I just write their note?" And, after a long day of treating patients it's really hard to sit and write several notes. Since these notes are needed to justify the continuation of therapy, keeping current on them is important though.
The notes themselves must show progress towards goals. The progress may be slight, but if the patient is making gains towards their stated goals then therapy is justified to continue. With my Fieldwork students I try to explain that each note must not only show progress, but their words must "paint a picture" of the patient so that a person who has never seen this patient can "see" what this patient is capable of by reading your note only.
Until next time, hope all your "Thoughts" are Good-
Tim