UPDATED MARCH 5, 2025
Introducing Structured Goals and More Updates to the Assessment & Plan Sections
In a continuation of Provider App enhancements from summer and fall 2024, we’re now beginning to roll out new updates to the Assessment and Plan sections of the SOAP notes process. Like the previous updates to the Subjective, Objective, and Treatment sections, these improvements will make your documentation process easier and faster and result in more consistent documentation for the VA!
Central to these updates is the introduction of trackable recovery goals that you will work toward with each patient. These goals will facilitate:
- Improved monitoring of patient progress
- More productive dialogue between you and your patients about their condition and recovery
- Better patient status reporting to other members of the patient’s care team, both for progress tracking and RFS consideration
Best of all: They’re automatically created for you! Let’s explore…
Goal Creation, Progress Tracking, and Patient Participation
There are two main goal types, which you’ll review with your patients each time you see them:
- GPS-based goals that are generated by our system based on the patient’s Global Pain Scale responses – these are required.
- Goals that you and the patient set together, which you will then enter into the app – these are optional.
GPS-Based Goals
At least two of these goals will be set at the start of each referral, based on the following:
- Patient’s overall GPS score
- Patient’s score in the “Activity” section of the GPS
- Patient’s reported pain medication usage (if any)
- Patient’s reported missed workdays due to pain (if any)
Because you administer the GPS on the 1st, 5th and 10th appointments in a referral, you will review progress towards these goals on each of these appointments.
- During the 1st appointment, you and the patient will review the goals automatically generated from their GPS answers.
- In the 5th (midpoint) appointment, after administering the GPS again, you will be able to see the patient’s progress towards the goals. If any goals have been met, new ones will be created based on the new scores. You should review this progress with the patient.
- In the 10th (RFS) appointment, you will administer the final GPS questionnaire and again review any progress the patient has made toward their goals.
Optional Patient Goals
In addition to those generated by GPS responses, you can set up to two additional goals for this course of treatment. Remember that they should be measurable in such a way that you can determine if the goal has been met. A few examples:
- Improve lumbar flexion range of motion from severely limited to no limitation to improve the ability to lift objects from the floor.
- Decrease pain from 8/10 to 2/10 to allow the patient to sleep through the night without waking.
You should review these goals with the patient in every session and indicate their progress. At any given time, you can have up to 2 optional goals, so if the patient meets one, you can add another into the app.
See how the “Review Goals” section works here:
Plan Section: Where the Goals Come Together
The goals set for the patient will be the basis of the “Plan” section of the SOAP notes. While there is an optional text box, the Plan section will consist primarily of the structured goals, as described in the section above.
See how it all works in this video:
Assessment Section: Simpler, Quicker, and Easier to Complete
As with the Treatment section, we’re simplifying this part of the documentation process by providing prompts for you to indicate how the patient is responding to the treatment and structured ways to add more details based on that initial response. Your selections, plus an optional free-text box, will be used to generate a basic Assessment for you. You should then provide additional information on the patient’s progress and how you and the patient feel they are responding to treatment.
See how the new Assessment section works:
Note that these updates are being rolled out to a limited set of therapists initially, before going live network-wide over the next few weeks. Interested in being a Zeel Provider App beta tester? Email help@zeel.com with the subject line “I want to be a beta tester” to let us know!
As always, we value every provider’s feedback. If you have additional ideas on how we can improve your experience, please submit them here. Every suggestion will be reviewed by our product and clinical teams.