Rethinking Value in Documentation 
                            
                  Reference Guide 
      
      
      
      
      
      
      
      
      
      
      
      
      
      
                                   
                                 Matthew Connell, MPT 
                                 Cindy St. Pierre, PTA 
                                 Julie Catlin, PTA 
                                 Ivett Lopez, PTA 
                                 Marina Bakaeva, PTA 
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
       The purpose of the Reference Guide is to assist users in adding value to their clinical 
       documentation and improve the user’s ability to create quality documentation in a more 
       efficient and timely manner. The Reference Guide is divided into nine sections designed to 
       facilitate understand of the key components of documentation. After utilizing the Reference 
       Guide, it is our hope the user will feel confident in completing accurate clinical documentation 
       that effectively demonstrates skill, necessity and value. The Reference Guide, utilizes the SOAP 
       note format but is applicable to all types of documentation styles.  
                       Contents 
   Getting the Most from the Reference Guide: ........................................................................................ 5 
   Why Is It Important to Have Documentation? ..................................................................................... 6 
    Communication with Other Professionals ........................................................................................... 6 
    Clinical Decision Making .................................................................................................................... 6 
    Legal Record of Patient Management .................................................................................................. 6 
    Documentation Guidelines ................................................................................................................. 6 
    Things to Include in Value Based Documentation: .............................................................................. 7 
   How to Convey Skilled Intervention in Daily Notes .............................................................................. 7 
    Progression of Care and Ongoing Assessment in Daily Notes .............................................................. 8 
   Correction of Errors6 ........................................................................................................................... 8 
    Handwritten Documentation: ............................................................................................................ 8 
    Electronic Documentation: ................................................................................................................ 8 
   Sections .............................................................................................................................................. 9 
    Subjective.......................................................................................................................................... 9 
     Things Which Should Be Included In the (S) Section of The Note. .................................................... 9 
     Subjective This vs. That ................................................................................................................ 10 
    Objective ......................................................................................................................................... 11 
     The Focus of the Objective Is Twofold: .......................................................................................... 11 
     Information to Be Included in the (O) Section of the Note: ............................................................. 11 
     Examples (O) Section of the Note: ................................................................................................ 12 
     Common Mistakes Made in (O) Section of .................................................................................... 13 
     Common Pitfalls In (O) Section of the Note: ................................................................................. 13 
     Objective This vs. That ................................................................................................................. 14 
    Assessment ...................................................................................................................................... 15 
     Checklist May Be Helpful When Writing the Assessment: ............................................................... 15 
     Common Errors Found in the (A) Section of SOAP Note: .............................................................. 16 
    PLAN .............................................................................................................................................. 17 
                               7
     The Following Information MUST Be Included in (P) Section  ....................................................... 17 
     The Following are Also FREQUENTLY Included in the (P) Section:7 ............................................... 17 
     Examples of the Plan .................................................................................................................... 18 
   Catch Phrases. ................................................................................................................................... 19 
    A .................................................................................................................................................... 21 
    C .................................................................................................................................................... 21 
    D .................................................................................................................................................... 21 
    I ..................................................................................................................................................... 22 
    L ..................................................................................................................................................... 22 
    N .................................................................................................................................................... 22 
    P ..................................................................................................................................................... 23 
    R .................................................................................................................................................... 23 
    S ..................................................................................................................................................... 23 
    T .................................................................................................................................................... 23 
    U .................................................................................................................................................... 24 
   Common Medical Abbreviations ....................................................................................................... 25 
   Reference ......................................................................................................................................... 34