SOAP guide
Plan and goals
What happens next and what the patient is working toward. Goals are structured records on the episode; the plan of care is a structured treatment plan plus a signed note; each visit's plan is your own text. AI never decides any of it.
Written for: Physical therapists · Occupational therapists · Speech-language pathologists · Clinical leads · Clinic administrators
What is available
| Capability | Status | What that means here |
|---|---|---|
| Goals with baseline, target and date | Available | Goals belong to the episode: your wording, optionally measured against a range of motion or an MMT grade (joint, motion, side), with a baseline, target, target date and rationale. A goal is proposed, accepted by a clinician, and closed as met, partially met, not met or discontinued. |
| Short-term and long-term goal types | In development | Goals are not yet split into short-term and long-term. State the time frame in the goal's wording and target date. |
| Progress toward goals at each visit | Available | On a visit note you mark each accepted goal Progressing, No change, Regressed, Met or Not assessed today. It is your judgement; nothing is inferred. |
| Structured treatment plan and plan reviews | Available | One active plan per episode with interventions, visits per week, duration, discharge criteria, review date and physician certification details. Each review records the outcome, progress and changes to the plan. |
| Interventions provided, with focus | Available | Choose what you did from the service families offered for the episode's discipline (all of them on a multidisciplinary episode), then what it focused on and an optional detail. The list is a draft vocabulary. |
| AI deciding goals or the plan of care | Not available | AI does not write goals, plans of care or treatment decisions. The AI draft's Plan section only restates the plan you typed for the visit, your dictated summary or the active plan of care. |
Where the plan goes in each note
| Note type | Plan sections |
|---|---|
| Visit note | Plan - next visit |
| Initial Evaluation | Measurable goals; Plan of care |
| Plan of Care & Goals | Measurable goals; Planned interventions; Frequency & duration; Plan of care. Fill from the treatment plan copies the structured plan in. |
| Progress Report | Updated goals (optional); Continued plan of care |
| Re-evaluation | Revised measurable goals; Revised plan of care |
| Discharge Summary | Recommendations |
Goals: the structure that exists today
Goals belong to the episode, not to a single note, so the same goal is reported against at every visit, in progress reports and at discharge. Each goal has:
- Goal - your wording: "What the patient will be able to do, and under what conditions."
- Measured against - Nothing (the goal is stated in words), Range of motion in degrees, or Muscle strength on the 0-5 scale. A measured goal also takes joint, motion, side and, for range of motion, active (AROM) or passive (PROM).
- Baseline, Target and Target date.
- Rationale - "Why this goal, for this patient, now."
A goal is Proposed, then Active once a clinician accepts it, and closes as Met, Not met or Discontinued. Closed states are final: a goal that was met and later lost is recorded as a new goal, so both facts stay in the record. An episode can hold up to 50 open goals.
- Open the episode and go to Treatment plan, then the Goals panel (the Goals link in the episode's jump navigation takes you there).
- Choose Add goal and write the goal.
- If it is measured, choose what it is measured against, then joint, motion, side and range type.
- Enter the baseline, target, target date and rationale.
- Choose Add and accept to put it on the plan of care under your name, or Propose only to leave it for another clinician to accept.
Example (synthetic patient)
PT goal, measured
Goal: "Patient will ascend and descend a flight of stairs with a handrail, independently, to access their home."
Measured against: Range of motion, knee, flexion, left, AROM. Baseline 92, target 120, target date six weeks from the evaluation.
Example (synthetic patient)
OT goal, in words
Goal: "Patient will don and doff the wrist hand thumb orthosis independently and follow the night-time wearing schedule." Measured against: Nothing - stated in words.
Example (synthetic patient)
SLP goal, in words
Goal: "Patient will name common objects with a phonemic cue or less in 8 of 10 trials." Measured against: Nothing - stated in words. Trial data recorded at each visit supports progress.
Progress toward goals at each visit
On the visit note, Quick Capture lists each accepted goal with Progressing, No change, Regressed, Met and Not assessed today. It is your judgement - "Nothing is inferred" - and it feeds the visit note's Assessment and the progress report's summary of each goal. Marking Met here records progress at this visit; closing the goal itself is done on the goal.
Clinician-selected interventions
Planned interventions are your text in the plan of care and the treatment plan. What you actually provided at a visit is selected in Quick Capture under What you did: a service family, then what it focused on, then an optional detail. Only the families for the episode's discipline are shown (all of them on a multidisciplinary episode), plus any family that already holds a selection.
| Family | Offered to | Focus examples |
|---|---|---|
| Therapeutic exercise | PT, OT, SLP | Strength, Range of motion, Flexibility, Endurance, Motor control |
| Neuromuscular re-education (includes Balance training) | PT, OT, SLP | Balance, Proprioception, Postural control, Vestibular / gaze stability |
| Manual therapy | PT, OT | Joint mobilization, Soft tissue mobilization, Scar mobilization, Manual edema management |
| Gait training | PT, OT | Gait pattern, Assistive device, Stairs / curbs, Uneven surfaces |
| Therapeutic activity | PT, OT, SLP | Transfers, Bed mobility, Lifting / carrying, Reaching / overhead tasks |
| Self-care and home management | PT, OT | Dressing, Bathing / showering, Meal preparation, Home safety |
| Swallowing treatment | SLP | Oral motor, Swallowing exercises, Compensatory strategies / postures, Food / liquid trials |
| Speech, language and cognitive-communication treatment | SLP | Word finding, Articulation, Voice, Executive function |
| Other skilled treatment | PT, OT, SLP | Cognitive / perceptual training, Fine motor / dexterity training, Splinting / orthotic management, Caregiver / family training, Patient education, Home exercise program reviewed, Heat / cold, Electrical stimulation, Other |
Selecting an intervention states what you did. It does not make anything billable. See Treatment activities.
Follow-up, reassessment and plan changes
| Task | How it is done today |
|---|---|
| Plan for the next visit | Free text in Plan - next visit, or typed under Your plan so Build from your selections and the AI draft use it. |
| Frequency and duration | The structured treatment plan: visits per week and duration in weeks, with a review date. |
| Reassessment | A Progress Report when due (your administrator sets the cadence in visits and/or days; with no policy set, nothing is shown as due) or a Re-evaluation when the condition changes. |
| Plan review | Record review on the treatment plan: Outcome, Progress and Changes to the plan. |
| A new plan | A new treatment plan replaces the old one only when it is signed; open goals move across. |
| Follow-up after discharge | Recorded when the episode is discharged, with the aftercare plan. |
AI recommendations are never an approved plan
The AI draft's Plan section may only restate the plan you typed for this visit, your dictated summary or the active plan of care; a Plan citing none of them is emptied with the message that the draft does not decide treatment. Build from your selections uses your typed plan, or "Continue the plan of care." followed by the plan of care text.
Troubleshooting
- A goal is not offered for progress on the visit note: it is still Proposed. Accept it first.
- Cannot reopen a met goal: by design. Add a new goal.
- "No plan of care is active and no plan was written for this visit": type a plan under Your plan, or record a plan of care.