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.