Writing SOAP Notes: with Patient/Client Management Formats, ed 3.

Writing SOAP Notes: With Patient/Client Management Formats, ed 3 Kettenbach G. Philadelphia, PA 19103, FA Davis Co, 2004, paperback, 223 pp, ISBN: 0-8036-0836-5, $28.95.

This book is intended for use by students or new practitioners to help them understand and apply note writing using SOAP notes (which are based on the work of Weed) and a patient/client management note format that is consistent with the patient/client management model described in APTA's Guide to Physical Therapist Practice. The author begins by clearly and succinctly providing the reader with basic information about note writing, the purpose and importance of documentation, a description of the 2 types of notes highlighted in this book, and elements essential to the medical record. In the third chapter, "Medical Terminology," the author apparently has assumed that the reader has already studied medical terminology. She provides no background on medical prefixes, suffixes, and word roots, but she refers the reader to other texts that do so. This chapter provides 2 brief worksheets that readers can use to test their knowledge of medical terminology. These worksheets are in no way extensive, but they serve as an example of how to identify the meaning of words or phrases.

The chapter, "Using Abbreviations," cautions readers to identify the rules on acceptable abbreviations at each worksite, and then provides several pages of standard, commonly accepted abbreviations used in physical therapist practice. A few examples are provided, followed by 2 worksheets for the reader to complete. All other chapters that teach a skill include appropriate worksheets.

With the essential foundation established, subsequent chapters describe the history and how to write systems reviews and document tests and measures in the patient/client management format. The author then intersperses 2 chapters on writing SOAP notes, describing the subjective (S) and objective (O) data that would be included. Following these chapters, the author briefly describes essential elements for the physical therapist in documenting the diagnosis and prognosis, referring to both the SOAP and patient/client management note formats.

These chapters and subsequent chapters on documenting the plan of care through the establishment of long-term goals, short-term goals, and planned interventions are well written and comprehensive; however, the book could be a little confusing for the beginning reader because the author mixes the 2 note-writing formats (SOAP and patient/client management) in the text of these chapters. An appendix, however, illustrates the elements of the patient/client management note, the patient/client management process, and essential elements of the SOAP note, highlighting the similarities of the various elements. Although the text mixes the different formats of note-writing style and may be a little confusing to the beginning reader, this appendix is highly valuable because it summarizes the differences between the formats. An additional chapter on alternatives to these 2 note-writing formats (eg, reference to standardized documentation forms, a brief reference to Medicare forms, and a description of computerized documentation) also is provided. In addition to the appendix described above, other appendixes include answers to the worksheets and summaries of the patient/client management note and SOAP note contents as well as excellent tips for note writing for third-party payers and a relevant bibliography.

The scope and depth of this book is consistent with the intended audience, and the subject matter, for the most part, is comprehensively covered. Although the book provides instruction in note writing using the long-standing SOAP method, its introduction of a new format that addresses elements of the Guide to Physical Therapist Practice makes this work more contemporary and provides the reader with alternative methods for documentation. The inclusion of worksheets following chapters that teach a skill is an asset because the progression of the worksheets requires a demonstration of skiffs that build on material in previous chapters. The layout of some portions of the book (eg, the table of contents and a few pages that had multiple "boxed" examples that almost outnumbered the text) was visually distracting because of the style of the printing. Once the reader looks beyond these few examples of "busy" layout, however, they can appreciate the essential content. Overall, the author has clearly achieved her goal of providing a text for students and practitioners who are beginning professional practice to help them hone their documentation skills.

Paulette M Cebulski, PT, PhD

University of Michigan-Hint

Hint, Mich

Dr Cebulski is Director of the Physical Therapy Department. Previously, she was Academic Coordinator and Center Coordinator of Clinical Education, and she now teaches in the areas of physical therapist practice management, professional orientation, and current issues in physical therapy practice.