Record keeping is an essential aspect of effective patient care in hydrotherapy. SOAP notes are a standardised method for organising patient information and treatment progress.
Format of SOAP Notes:
- Subjective: This section includes the patient’s history, owner observations, and any subjective information provided during the session.
- Objective: Objective observations made by the hydrotherapist during the session, including gait analysis, range of motion, and response to treatment.
- Analysis: An analysis of the patient’s progress, treatment response, and any areas that require attention or adjustments.
- Plan: The plan outlines the treatment goals, exercise modifications, and any changes to the treatment plan based on the analysis.
Keeping SOAP Notes:
SOAP notes should be kept for each hydrotherapy session and should include:
- Date and time of the session
- Patient’s name and owner details
- Veterinary referral details
- Subjective information from the owner
- Objective observations made by the hydrotherapist
- Analysis of the patient’s progress
- Treatment plan and modifications made
SOAP notes should be well-organised, legible, and kept securely in a patient’s file for future reference and continuity of care.
Other Relevant Methods of Recording Information:
- Photographic Documentation: Taking photographs or videos of the patient’s gait, posture, and exercises can be useful for monitoring progress over time.
- Digital Software: Utilising specialised hydrotherapy software that allows for electronic record keeping and easy retrieval of patient information.
- Hydrotherapy Logbooks: Maintaining a logbook with detailed records of each session, including water depth, temperature, exercises performed, and the dog’s response.
- Communication with Veterinarians: Regularly updating referring veterinarians on the patient’s progress and treatment outcomes through written reports or direct communication.
Adhering to legal requirements for veterinary referral is crucial for hydrotherapy practice and patient safety. Detailed paperwork, including consent forms, medical history, and treatment plans, ensures a comprehensive approach to patient care. SOAP notes and other recording methods facilitate effective communication, treatment evaluation, and progress monitoring, ensuring the best possible outcomes for canine patients undergoing hydrotherapy.