The SOAP Note: Subjective
Welcome back to our series on documentation and patient notes. Don’t forget to check out our other SOAP note posts…you can check them out here:
Do you know what I have come to love about doing notes for my patients?
I get to write a story about their life every time they come into my office. I get to update their book every time I meet with them face to face and I don’t want to miss this opportunity to write the best biography I can. The Subjective portion of your SOAP note does not have to be long, but it has to be unique and specific to your patient.
Welcome to the first in our series on SOAP note writing on established patients. SOAP notes are critical for you as a doctor, clinician, or therapist to protect you and your patient, and to make sure that you get paid in a timely manner. Today we’re covering the SOAP portion of the note and we want to make sure that you feel confident that when you write your Subjective portion of the SOAP, you’re doing it right, and you’re meeting the standard.
So what do I put in the SUBJECTIVE portion of the note?
There are a couple of things that must be in your Subjective.
How Have They Been?
You must document how the patient has been doing the last visit and it is best to use their own words to do so. Here’s some examples:
- “I’ve felt great since your last treatment”
- “My back pain increased the day of your treatment, but I felt so much better the next day.”
- “I’ve had a headache since I did the core exercises in your office.”
Specific on Location
Be specific on where they are currently experiencing pain or symptoms. Here’s some examples:
- “He is experiencing tightness upper back and he points to his trapezius muscle region where it attaches to the scapula.”
- “Her right knee continues to be painful and she points to the tibial tuberosity to describe the location today.”
- “She continues to have tightness during volleyball with her swing and she uses her whole hand placed over her right triceps muscle to describe the location of the tightness.”
You also have to document on if your patient has followed your specific instructions for at home care, or out of the office care.
We all give at home instructions even if you tell your patient to rest for the entire day after your treatment. You document this in your Subjective note. Here are some of the examples of documenting instructions:
- “He complied with resting after the first treatment on Thursday by going home and relaxing on the couch. He watched three movies and took a 2 hour nap. On Friday, he returned to work and felt much improved while sitting at his desk.”
- She was to do her assigned hip flexor stretch 3 times on Monday, 4 times on Tuesday, and has stretched 2 times today before her treatment.”
- “He reports that he went directly to his office and adjusted his workstation so that it complied with the recommendations that were giving on Tuesday (June 12, 2015). He did have trouble adjusting his keyboard height because he has not been assigned an ergonomical keyboard. He has put in a work order for this to be resolved.”
You also have to document when the patient does not follow through with your recommendations. As a provider, you can’t “fix” a patient, but rather you’re the catalyst that helps them “fix” themselves. What happens when you don’t follow through with their recommendations? It must be documented. For example:
- “She has not stretched her hip flexors since they were assigned on Tuesday.”
- “He did not adjust his workstation as was recommended on Friday, and he does not plan to do so.”
- “She was given a hot pack on Tuesday to be able to apply moist heat 2 times per day, but she has been to busy to apply the hot pack at home.”
This is also where you put thier performance indicators and improvements in outcome assessments that were noted in the initial exam. Here’s some examples:
- “She was able to sit for 5 minutes today for the first time in 6 weeks. In the past, she has not been able to sit without pain. She stood up and went for a walk before the pain began.”
- “She went for a run today and only started to tighten up after the 3rd mile. 20 days prior, she was only able to run for 1/4 mile before she started to tighten up in her lower back.”
- “The Back Bournemouth Questionnaire completed today showed a 56% improvement in score, and she significantly decreased her ‘anxiety of movement’ score from a 9 to a 3.”
And lastly, you might also have to include mandatory reporting requirements. For example, The Joint Commission requires a pain scale be given during each visit. So it is essential that you ask and report their pain scale from 0-10.
Putting The Subjective Together
So to summarize the Subjective portion of the note, it has to be quality reporting that tells the patients biography. What the patient reports is a critical portion to their care and it allows you to follow along with their progress.
So here is an example of a complete Subjective:
The patient reports that he is still experiencing lower back pain and he points to his left quadratus lumborum region to describe the location of the pain and he rates his pain a 3/10 this morning. After his treatment on Monday, he had a decrease in symptoms that began immediately after treatment and lasted until he awoke the next morning. Once he got to work, his pain returned and was intense by the time he stopped for lunch on Tuesday.
He did not adjust his chair height and he did not put his feet up on two reams of paper as assigned on Monday. He did, however, utilize the moist heat on Tuesday after work for 39 minutes as assigned.
He went for a walk on Tuesday evening and was able to walk for 1 1/2 miles without pain. This is an improvement from Sunday’s walk where he could only walk 3/4 mile without pain. He stated that he was very excited because one of his main goals is to lose weight and the increased walking has always helped him lose weight in the past.
It’s not long, but it is a well written biography of how your patient is doing with treatment, how they are complying with your assignments, the mandatory reporting requirements, and how they are meeting their performance standards. It’s easy when you know what to ask and write!
Let us know what you think about the Subjective in the notes below, and know that ChiroPractice Pro is here to help you be compliant and to make writing your notes easy so that you can enjoy your life and your practice…not worry about doing notes!
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