Critical Thinking

Out with SOAP, In with PAOS: The Value of Restructuring Our Therapy Notes

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It’s a right of passage and a matter of practice…the glorious SOAP note. Subjective, Objective, Assessment (or Analysis) and Plan. Recall when we struggled to write our first several notes. We wondered what qualified as pertinent Subjective statements and how to keep O and A separate. Even P was a bit tricky out of school. Now, most clinicians have achieved SOAP wizardry. We can write these notes in our sleep. Even upside down and blind-folded.

However a nagging question presents — has S-O-A-P been the right order? This is a matter of perspective.

SOAP notes seem to be most beneficial for the writer. Perhaps this is why we’ve been trained in this format and why it has persisted. The SOAP format pulls the author through the note in accordance with the sequence of the therapy session. The logic makes sense.

However from the reader’s perspective, P-A-O-S notes seem far superior. To test this theory, we surveyed our PCPs who consistently confirmed PAOS is the order of interest as they review our notes. They seek actionable information first and are least concerned with Sally’s report of walking okay at the birthday party last night. This might sound trivial but remember PCPs are busy and may review 70 minutes of documentation each day. We owe it to our referral sources to make our information easy to locate. Help them avoid scrolling through EHRs and flipping paper pages in search of the P.

Also consider the benefit of a PAOS note for the covering therapist who needs a quick way to get caught up on the previous session. At our organization, we implemented PAOS with success. We added a robust P that includes a specific plan for the very next session. This helps easily convey information in the event a staff is unavailable or calls off.

So, assuming I’ve convinced you — why aren’t PTs writing PAOS notes? Writing the Plan first is not intuitive for the author. As a matter of fact it is quite challenging. Just as we learned the SOAP format we can adjust to the PAOS sequence.

Present this at your next staff meeting. Ask your PCPs and RN Care Managers for feedback. Start a pilot with an aspiring PT and let us know what you find.

Alan Petrazzi, MPT, MPM
Pittsburgh, PA

The author is a licensed physical therapist with several years experience as a Rehab Director in large healthcare systems. Currently he is an administrator overseeing Primary Care services for over 35,000 unique patients. The opinions expressed are those of the author only and may not reflect the opinions of his employer.

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  1. Interesting idea. Unfortunately most companies i deal withpaper in the home care setting where I work is more structured in the soap format. Less open ended soap note formats now and more check box with narrative sections to prevent poor documentation. I do like the idea however, makes since having the plan first.

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