soap notes are documents used by health care providers to record the client’s medical charts however SOAP stands for Subjective, Objective, Assessment and Plan and Therapy note is record of the patients ,now a day’s most of the therapy notes are written in Soap format.
Each element of soap notes has a particular meaning to it like the Subjective part contains the history of patient’s illness his/her medical history as well his family’s medical history. The objective part contains information regarding the tests done on the patient. The assessment part consists of the assessments of the problems and the summary of the client etc and finally the plan part is the course of treatment. It helps improve the overall treatment system because it shows the assessment, problems and plans in an organized yet summarized way that’s why when it comes to writing it one need not write complete sentences abbreviations are enough but one must take care while using abbreviations as a small mistake can create huge problem.
therapy forms are very important because its designed to get information that helps the quality of both patient and overall service of the organization the major things included in the therapy forms are the previous attendance for the therapy the current attendance can also be included, the medication used by the patient, record of the present difficulties and its impact on the patients health and it includes demographic of the patient, waiting time etc.
Then comes the outcome of the therapy it’s also recorded and the information includes the length of the treatment, the type of intervention received as well as the frequency. This form contains data on the effectiveness of the service provided that includes the benefits of the treatment, the attendance and details regarding the ending of treatment and the recovery details.
Previously these things were done in a written format but now there are software’s that does these jobs.