What Goes Into a Visit Note?

Home health therapists play a crucial role in assessing and providing care for individuals in their homes. The SOAP note format (Subjective, Objective, Assessment, Plan) is a widely used method for documenting patient encounters. Here's a general guide on what a home health therapist should assess during a visit and how to document it in a SOAP note: 

Subjective

This section includes information provided by the patient or their caregivers.

• Chief Complaint:

  • Document the main reason for the visit, such as pain, mobility issues, or rehabilitation needs.

• Patient History:

  • Gather information about the patient's medical history, current medications, allergies, falls, and any recent changes in health. 

  • Remember, if the patient has a fall, even if it isn't with you present, an incident report should be completed! 

  • Since you're already talking to the patient, it is good to confirm that the patient has not had changes to their insurance (especially around open enrollment season!) or been hospitalized for 24 hours or greater since beginning home health.  If they have, please inform the agency ASAP and document a communication report.  

• Functional Status:

  • Assess the patient's ability to perform activities of daily living (ADLs) and any challenges they may be facing.

• Pain Level:

  • Ask about the presence, location, and intensity of pain. Use a pain scale to quantify the pain level.

  • Remember, intermittent, aggravated, or controlled pain should still be documented.  

• Medication Compliance:

  • Inquire about the patient's adherence to prescribed medications and any side effects they may be experiencing. If the patient has changes to their medications, this should be documented.  

Objective

This section focuses on measurable and observable data collected during the visit. For a PT, for instance, one should assess:

• Vital Signs:

  • Record the patient's vital signs, including heart rate, blood pressure, respiratory rate, and temperature.

• Physical Assessment:

  • Evaluate the patient's range of motion, strength, balance, and any physical limitations. Document any observed abnormalities.

• Functional Assessment:

  • Observe the patient's ability to perform specific tasks related to their therapy goals, such as walking, transferring, or using assistive devices.

• Safety Assessment:

  • Identify potential hazards in the home environment that may affect the patient's safety and well-being.

Assessment

This section involves the therapist's clinical impressions and analysis of the data collected.

• Diagnosis and Progress:

  • Summarize the patient's current diagnosis or condition and comment on any changes or progress observed during the visit.

• Response to Treatment:

  • Evaluate the patient's response to previous interventions or therapy sessions.

• Identified Problems:

  • List any new issues or concerns that have been identified during the visit.

Plan

This section outlines the therapist's plan for further interventions and care.

• Treatment Plan:

  • Specify the therapeutic interventions, exercises, or activities to be performed by the patient between visits.

• Goals and Objectives:

  • Set realistic and measurable goals for the patient's progress and outline steps to achieve them.

• Recommendations:

  • Provide any recommendations for equipment, assistive devices, or modifications to the home environment.

• Follow-up:

  • Schedule the next visit and outline any additional assessments or evaluations that may be necessary.