There are a variety of record formats used by physical therapists and other professionals for manual entry or paper-based systems as well as electronic or computerized records. Categorically, they include source-oriented, problem-oriented, and integrated systems.
The source-oriented medical record-keeping system (SOMR) has been commonly used in hospitals and skilled nursing facilities (SNFs) for decades. Each record or “chart” is divided into sections by profession or service (i.e., physical therapy, nursing, medical, physician orders, laboratory, etc.). Patient problems are not separated and notes between caregivers are not integrated because they are “parallel” in nature. Entries in each section are usually in chronological order. It may be time consuming for the physical therapist to glean patient information from the SOMR because of this structure. Additionally, within each section, the methodology for recording information may be different for each discipline, but each discipline should be consistent with itself.
A component of the problem-oriented medical record system (POMR), the SOAP (subjective, objective, assessment/analysis, plan) or SOAPIER (S, O, A, P, Implementation of plan, Evaluation of the implemented plan, Revision of the plan if necessary) note, is commonly used by physical therapists. Common use, however, should not be misunderstood to translate to the best or most effective or efficient for every situation. In an effort to improve patient record keeping, in 1958 Lawrence Weed, MD, of the University of Vermont began exploring alternative types of record entries. The POMR, developed in 1969, focuses on a patient's specific problems in an integrated and coordinated manner between professionals.1,2 Weed's system includes the initial assessment, problem list, initial plan, progress notes, and discharge summary. All patient problems are included and numbered, active (current) and past, and all professionals involved in the patient's care contribute to the list. In the “pure” system, only one problem can be addressed on a SOAP progress note. Physician orders, not included in the initial plan, are cross-coded for relevance by number to the problems identified. Notes in the POMR are recorded in the SOAP or SOAPIER format. Dr. Weed offered categories to assist professionals in clarifying information.1,2
|S||Subjective data (what the patient, family member, or significant other says the patient feels or is doing, only as relevant to specific episode of care and problem)|
Author's Note: Beware of inclusion of statements that are irrelevant to care or, out of context, may be misunderstood and result in denial of services.
|O||Objective data (what the professional performs, observes, or inspects in a reproducible manner as relevant to function as possible and clearly presented)|
|A||Assessment or analytical (summary of S and O with interpretation and professional judgment in order to justify care including progress toward goals if using SOAP only vs. SOAPIER)|