If you keep notes and you use the SOAP notes format:
* Subjective
* Objective
* Assessment
* Plan
you are supposed to write a plan as the last part of your notes. In my experience, the plan varies in detail from practitioner to practitioner. However, although I see the need to plan, I also see a great need to constantly assess and adapt treatment to the needs of the individual patient.

I tend to have a plan in my head, which is based on the whole of the last treatment:
* Their response to the previous treatment
* The tasks they have found difficult/painful this week
* The response to the treatment that day
* Progression relative to the healing of the injury

All of the above are in my head all the time while I am treating. My main goal depends on the patient, their injury and what is achievable in that session.

My difficulty with the SOAP notes plan is that there is often a week between treatments. How do you know the effects of the treatment from the first week to plan your next treatment? I personally tend to use the plan to provide reminders of where to go strategically, rather than getting too specific as a week can be a long time in the life of an injury or dysfunction.

I also find that with Functional Therapy I am able to make quite rapid changes in 30 minutes and that in conjunction with their exercise programme I might need to totally re-assess their current state on the next appointment, because my initial assessment is already out of date. I often even see kinds of changes during a single session so I would have to re-assess one joint having worked on another, and thus made changes to the whole kinetic chain.

For example, a hip that seems to be completely locked down may free up once I have finished working on their foot, therefore my “plan” to work on their hip would now be a waste of time. Therefore, I favour continual assessment over the reliance upon a single initial assessment to make a plan.

Although I am sure many practitioners think like this, it’s not often talked about and I have often seen very detailed plans for patients. I think an over-arching plan is important, but there needs to be a working flexibility that allows you to adapt not just between sessions but within sessions. Assess, treat, assess, treat is the only way for me, as you never know what effect treatment will have on function.

In the long run it will save a lot of time and it has the added advantage of helping you build a functional profile of the patient, which is invaluable when trying to resolve complex and long standing dysfunction.

Neil Poulton