SOAP Notes – Treatment Section and Check Out Guide

The Treatment section of the SOAP note documents the therapeutic techniques and education provided during a session. It uses structured inputs (checkboxes, dropdowns, and prompts) to simplify documentation while ensuring compliance with VA and clinical standards.

🟢 1st Appointment – Full Treatment Documentation

During the first appointment in a referral, providers will complete the Treatment section after completing the Objective evaluation and before submitting the SOAP note.

🧾 What to Document:

1. Body Part(s) Treated

   • Click the “+” icon to add each area treated.

   • Select modalities/techniques used for each area (e.g., Swedish, trigger point therapy).

2. Patient Education

   • Indicate if patient education was provided.

   • If yes, select up to three education topics (e.g., posture, hydration, stretching).

   • Education empowers the patient, supports functional independence, and improves outcomes.

3. Clinical Attestation (Checkout Section)

   • Attest to actual hands-on treatment time using CPT code 97124 (timed code).

   • Choose from the following time blocks:

     • 23–37 minutes → Bill for 2 units

     • 38–52 minutes → Bill for 3 units

     • 53–67 minutes → Bill for 4 units

4. E-Signature & Checkout

   • Confirm and sign off on the date and duration of services.

   • Press “Checkout and Submit” to finalize the SOAP note entry.

🔒 Reminder: Once you complete the Review & Submit step, the Treatment section becomes locked and uneditable.

🔁 2nd Appointment and Beyond – Prepopulated & Streamlined

From the second appointment onward, the Treatment section is pre-populated with your previous session's entries.

✅ What to Do:

• Review body parts treated and techniques used.

• Update any changes in the treatment approach.

• Complete the Patient Education section.

• Re-attest to the duration of hands-on care with the appropriate billing time.

• E-sign and submit the SOAP note via “Checkout and Submit.”

✏️ The Treatment section remains editable until the Review & Submit step is completed.

⚠️ Best Practices

• Always confirm that techniques and education topics reflect what was actually performed during the session.

• Ensure time billing matches actual treatment time and aligns with CPT code guidelines.

• Use clear clinical reasoning for treatment choices, especially when altering care plans or progressing techniques.

• For VA compliance, remember:

  • First appointment = 30 minutes

  • Max allowed per day = 60 minutes

  • No back-to-back sessions allowed