Functional Documentation: A Process for the Physical Therapist

Documentation of the treatment process is an important part of any therapeutic regimen. As a record of client care, it provides useful information for the practitioner, other members of the health-care team, and third-party payers. Marcia Stamer has produced a valuable guide to documentation for physical therapists. She describes the S.O.A.P. method of documentation, widely used by doctors and insurance companies. In addition, she demonstrates that dividing notes into Subjective, Objective, Assessment, and Plan areas illuminates the client's strengths, problems, and goals, making treatment decisions clearer. Stamer demonstrates that this method can make documentation an effective foundation for treatment.