Article: Clinical Note Taking for Pilates (SOAP)

As we continue our drive as a profession, it is important that we maintain correct policy and procedure in caring for our clients. For all of us, we indeed do this with our skills as an instructor in the studio itself. We must continue this due diligence by maintaining accurate records of each client at each visit.

Unfortunately it is a real possibility that one may be litigated against. If we can demonstrate that we follow our own strict policy in gathering and recording information at each visit, and demonstrate accurate repetition, we will stand in good stead with our clinical procedures.

• Follow the SOAP; Subjective, objective, assessment and plan method.
• Always conduct a full initial assessment and record all of the details around your subjective and objective findings. Here you may also indicate a determined level of skill of the client, their goals, your goals as a practitioner, any risk factors and a program plan.
• Subsequent notes may be a little more brief, but still follow the SOAP.
• Even if taking a studio session of 2-5 people, administrative time should be allowed for correct note taking for each client at each visit.
• Mat classes are suggested to have brief case note entry. This may be any relative subjective accounts noted and under plan document the pitch of class (eg: pre-natal, general beginner, general advanced, rehabilitative).
• Ideally, we should conduct an individual re assessment every 6 weeks with a revised plan.
• Sign and date each entry.
• Case notes need to be saved for 7 years by law.
• Case notes may be soft or hard form, but need to be legible.

Many instructors say that they just don’t have the time to take case notes. All medical and allied health practitioners must take notes by law and can indeed be deregistered on the basis of insufficient note taking, even if their service and skill is outstanding.  As we move toward being recognised as a strong profession and work toward continued recognition with Health Insurance companies case note taking indeed is becoming a significant part of our occupation.

Jen Guest

PAA Member, Physiotherapist at Smart Health Training