Progress reports are entered through the SOAP note system. The note system will ask you for a report when there are either 2 weeks left in the prescription or 2 sessions left in the prescription. The report is important because in many circumstances it will pave the way for the next prescription and reduce lapses between treatment plans. (If there have been less than 3 sessions done on a particular treatment plan, it will not ask you for a report.)
If multiple therapists have worked on the client, it can be a judgement call on who is to write the report. It could be the therapist that did the most sessions. It could be the therapist that has done the most recent sessions. Use your judgement and if its not clear, talk with the other therapists who have worked on the client. If you’re still not sure, ask the office and we will decide for you.
It helps the client to do the report right away. Some doctors will read our report and the same day send out a request for more treatment. Sometimes it takes longer, sometimes they need to re-evaluate the client before they will request more treatment, but sending the report can help shorten treatment lapses between prescriptions.
If you haven’t already, let your client know that their treatment plan is expiring or has expired. Let them know whether you are recommending more massage, and tell them that even with our recommendation they may have to be proactive and talk with their doctor to get the next round going.
As you have seen, our SOAP note form is bare bones. Enough to meet the insurance companies minimum requirements without taking up much of your time. These notes mainly go to the insurance company and only a few nurse case managers even look at them. The report is your chance to give useful information to the doctor and the nurse case manager. I know, reports can be a pain, but if you think about how much time you saved with our simplified SOAP note, maybe it can feel good to invest a little more time on the report when the prescription is almost complete.
Here are some guidelines on each section of the report
What Has Improved - Pretty self explanatory. The more detail the better. Doctors like to see pain scale numbers despite their limitations.
What needs Further Treatment - What injuries or parts of the body need further treatment
Recommendations for Further treatment - How to treat the injuries from the last section. Specifically include the number of sessions per week you recommend.
Other Comments - This might include the reason why they didn’t finish their prescription, or that they didnt’ come to their appointments, or anything else that doesn’t fit in the other boxes.
How much detail to include? If the client has done a good chunk of treatments, then its appropriate to include a fair level here. Below are some examples of different levels of detail. (The examples are from when we used to use paper forms but they still apply)
