PTA DOCUMENTATION GUIDELINES
Writing SOP Notes
Abbreviations and Medical Terminology Use
Appropriate abbreviations and use of medical terminology are expected. At present the QEII HSC
does not have a list of accepted abbreviations available for staff use therefore it is best to check
with the attending Physiotherapist if you have questions about using a specific short form or term.
Complete and correct spelling of a word is necessary if not abbreviated.
Full sentences are not necessary if the idea is complete and concise.
Example:
Possible
The pt. states pain in right shlder. began 3 wks. ago Wed.
Preferred
Pt. states onset of pain on (date).
Writing Subjective (S)
The subjective part of the note is the section which states the information received from the patient that is
relevant to the patients present condition.
Items Included Under Subjective
An item belongs under subjective if:
The patient tells the therapist or assistant his or her emotions or attitudes (Example: Im
really angry about).
The patient voices a complaint.
The patient reports a response to treatment (Example: a decrease in pain intensity).
Use of Verbs
S statements frequently contain a verb, which indicates that the statement is subjective and not
taken from the chart.
Verbs frequently used are states, describes, denies, indicates, c/o.
Use of the Word Patient
The S section of the note should be brief, concise and complete. The word Patient may be abbreviated
to Pt. After its initial use, it does not need to be repeated in each sentence. It is assumed, unless
otherwise stated, that the information in this section came from the patient.
Example:
Possible:
Pt. c/o pain in low back area. Pt. denies pain at rest. Pt.
states is unable to work or perform most ADLs because pt.
cannot sit >5 min due to pain.
Preferred:
Pt. c/o pain in low back area. States pain s with rest; is
unable to work or perform most ADLs because cannot sit > 5
min. due to pain.
Quoting the Patient Verbatim
At times, quoting the patient is the most appropriate method of conveying subjective information. Some
reasons for using direct quotes from the patient or a family member might be
To illustrate confusion or loss of memory. (Example: Pt. frequently states, My mother
will make everything all right. I want my mother. The patient is 80 years old).
To illustrate denial. (Example: Pt. states, I dont need home health PT. Ill be fine once Im
in my own home. The patient is dependent in amb & lives alone.)
To illustrate a patients attitude toward therapy. (Example: Pt. stated, I dont think any
therapy can get rid of my pain.)
To illustrate the patients use of abusive language. (Example: Pt. stated to therapist, Keep
your __ hands off of me.)
Writing Objective (O)
The objective part of the note consists of objective observations and measurements. Testing procedures
should be repeatable and comparable to previous notes.
Items Included Under Objective
An item belongs under objective if:
It is an objective measurement or observation or a part of the treatment given to a
patient such as, number of repetitions tolerated, pain relieved or caused.
This documentation provides information to anyone who
might treat the patient as to what was done in therapy on
a certain date. It is also done to inform those who might
read the medical record as a legal document of what
specifically was done with the patient.
It is a patient education activity (particularly specific exercises taught to the patient).
It outlines the patient reaction to treatment.
Example:
O: Pt. Ambulated 40 meters in 5 min. period with a single cane
indep.
Example:
O: Treatment given: Isometric hams & gluts, 10 reps x 3
QOR, 10 reps x 2
SLR, 10 reps x 3
Example:
O: Home exercise program reviewed. Pt indep. with
exercises provided.
Further Examples:
Example:
O: Pt. received 30 min. of gait training. Responded well to
verbal cues.
Example:
O: Treatment provided: US 1.0W/cm, 3 mhz pulsed x 5 min.
ant. shlder.
Organization
Information should be organized, easy to read, and easy to find.
Example:
Possible
O: Pt. tolerated exc. program well. Ambulating with crutches
PWB LE x 6 meters SBA. Exercises completed include:
QOR, 10 reps x 3
SLR, 10 reps x 3
Education given re. gait encouraging step through instead
of step to pattern.
Preferred
O: Ambulating with crutches PWB LE x 6 meters SBA.
Education given re. gait encouraging step through instead
of step to pattern. Exercises completed include:
QOR, 10 reps x 3
SLR, 10 reps x 3
Pt. tolerated exc. program well.
When the Patient Status has Not Changed
When writing a progress note for the patient whose status is unchanged the present status should be
outlined.
Example:
Possible
O: Transfer: Unchanged from last treatment session.
Preferred
O: Transfer: Requires mod + 1 assist Supine sit.
Use of the Word Appears
If something cannot be stated in measurable terms, the word appears instead of is should be used.
Example:
O: knee ROM not measured on this date but
appears functional for transfers w/c mat.
The term appears should be used cautiously; third party payers will not provide reimbursement for
intervention that appears to be needed.
Common Mistakes in Recording Objective Data
Some of the most common mistakes in recording objective data are
1. Failure to state the affected part
2. Failure to put things in measurable terms
Objective Measures and Observations for Use in
Recording Objective Data
May include but not limited to the following:
Edema:
Circumferential measurements
Pitting
Endurance: Vital signs (BP, respirations, pulse) before treatment,
after treatment, and recovery times
Signs of fatigue
Activity (describe) and amount of activity tolerated (time)
Perceived exertion scale
Walking test, amb. profile (using a form or data base
sheet)
Gait analysis:
Always include:
Type & amount of assistance
Equipment needed
WB status
Distance
Include as necessary:
Time
Type of surface (level, rough, inclines, stairs, 1-step elevation)
Gait pattern/deviations
General appearance:
Atrophy
Skin condition
Method of transport to PT: Cart/stretcher
W/C
Assistive device
Assistance necessary
Muscle tone:
Increased or decreased tone and where
Normal, hypotonic, hypertonic, spasticity, rigidity
Posture:
Pulse:
Sitting, standing, supine, prone
Beats/minute
Respiration: Side/position
Area
Minutes
ROM:
Active or passive or active assisted
Degrees (using goniometer)
Sensation:
Absent, intact
Temperature
Skin/wounds:
Size
Color/ appearance (pink/ red, purplish)
Drainage (green, none)
Odor (none, moderate, foul)
Location
Transfer ability:
Type and amount of assistance
Type of transfer
Equipment needed
Recording Treatment
Here are some things to consider and include when recording the patients treatment.
Modalities:
Which modality
Where
How long
Intensity, frequency
What position
Examples:
US: W/cm, time, where, position, reaction
Electrical stimulation: Type of current, type of
contraction, where, time, position
Ambulation:
Distance
Level of assistance
Assistive device(s)
Ambulatory aid(s)
Time
Wt. Bearing status
Type of gait pattern
Exercise:
Extremity or trunk
Position of patient
Types active assisted, active, resisted
Repetition - number
Resistance or wgt. used
Equipment used
Writing Plan (P)
The plan portion of the note contains the plan for the patients treatment. This differs from the situation of
describing the treatment and reaction to treatment in the objective portion of the note.
Example:
O: Tolerated 10 reps each of quad sets & SLR
to LE; on 10th repetition of SLR pts quadriceps were
fatigued & pt could no longer perform SLR.
P: Cont. with quad sets & SLR 3x /wk.
Items Included Under Plan
The following information may be included in the plan section of the note:
1. Frequency per day or per week that the patient will be seen
2. The location of the treatment (at bedside, in the department,
in a pool).
3. The treatment progression as determined in conjunction
with the Physiotherapist.
Example:
P: Will be seen 3x/wk. as an outpatient. Will receive pulsed US
to anterior shoulder at 1.5 W / cm for 5 min. PTA to
discuss introduction of exc. with PT.
Example:
P: Daily PROM & AROM exercises to shoulder at bedside.
Exercises will be followed with an ice pack to shoulder for
15 min.
If there is no change in the treatment plan initiated by the Physiotherapist, the plan outline may be
simplified.
Example:
P: Continue with established treatment plan.
Example:
P: Continue with present treatment.
Reference: Kettenbach, G: Writing SOAP Notes 2nd.ed. FA Davis, Philadelphia, PA, ______.
