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PTA Blog Talk

No More SOAP Notes

Published November 2, 2012 7:03 PM by Jason Marketti

With the advent of electronic health records (EHR) and the ever-changing resources we learn through computer documentation, there doesn't seem to be a need for the SOAP-note format. In fact, if SOAP notes are still taught in therapy school it may be a waste of time because fewer and fewer places are utilizing this type of documentation.

The SOAP-note format is effective when gathering and organizing data on a patient but is not suited for some of the computer programs available. The EHR that I currently use does not specify a place for subjective or assessment information. There is, however, plenty of space for objective data collection. And there isn't a specific place in the EHR for the "P" in the SOAP note.

Several EHRs are used by different companies (I've learned four in three years) and each one seems to only want certain information documented. Most have a drop-down menu with a point-and-click sentence structure. I seldom have to type any subjective information. One place I worked had a device like a personal digital assistant that you could carry around. It allowed you to document time spent with the patient and input which CPT codes were used with a drop-down menu if you wanted to briefly add anything to the note.

Is your facility still using the archaic SOAP-note format?


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About this Blog

    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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