Implementation of the problem-oriented progress note in a skilled nursing facility.

Abstract:

:Problem-oriented style progress notes were implemented in a skilled nursing facility where problem-oriented medical records were not in use. The problem-oriented note consists of subjective information, objective information, analysis or assessment of the problems, and plan for treatment, and is called a SOAP note. Six physical and occupational therapists used the method of note writing for an eight-week trial period. The author audited the records for errors in using the SOAP note throughout the experimental period. Therapists responded to a questionnaire following the study to assess their attitudes on using the SOAP note. Implementation of the problem-oriented progress note was satisfactory, with the exception of defining the problem list. The therapists reacted positively toward using the problem-oriented method of recording patient progress or status and recommended that its use be taught to physical and occupational therapy students.

journal_name

Phys Ther

journal_title

Physical therapy

authors

Shaughnessy MK,Burnett CN

doi

10.1093/ptj/59.2.160

subject

Has Abstract

pub_date

1979-02-01 00:00:00

pages

160-6

issue

2

eissn

0031-9023

issn

1538-6724

journal_volume

59

pub_type

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