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Supervisor's charting critique made me rewrite my whole system
I've been a PT aide for about 2 years and always thought my SOAP notes were fine. My supervisor pulled me aside last Tuesday and said my objective section read like a grocery list. She pointed out I was writing 'patient walked 50 feet' without noting the gait speed or assist level. That little push made me dig into the APTA's documentation guidelines. Now I time every transfer and use a stopwatch for gait, plus I write the exact cueing I gave. Has anyone else had a doc or supervisor totally reshape how they chart? What system do you use to keep notes consistent?
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robin_foster11mo ago
Did you catch that APTA article about how vague notes mess with insurance billing?
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