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Third-party payers cover medically necessary care within their definition.  At times, even with our patients’ best efforts, their healing does not progress as outlined in the plan(s). They may require a change in home care, DME, therapy type, CMT technique, or other.  What detail is necessary when the patient suffers an exacerbation within an existing plan?  We break down the Plan, part by part, to show how to fit the additional information into the current Assessment and Plan, including functional goals.

We encourage you to print these examples and place them in a plastic sheet for your quick, easy, and continued reference on documenting a change in plan. These are not cut and paste into your notes tools, but rather excellent examples for what type of information should be in the P of SOAP in a patient’s record.

The Anatomy of a Routine Office Visit Plan

The Anatomy of Subsequent ROV Note- Additional Exercises