Documentation in Aquatic Therapy

 

How do you document accurately so someone can replicate what you accomplished in the pool? It is not so straightforward because the parameters are many - depth of the patient, other turbulence in the pool, temperature of the water that day (can impact effectiveness), speed and position of execution (slow and controlled or fast with lots of resistence)... Of course it is all related to the goals you have but your effectiveness is in the details and the notes need to capture those details. 

Aquatic Therapy Rehab & Fitness, San Juan, PR, created a structured document for ease of sharing. I was asked to review and revise, leaving their content the same as terminology was different to what I use. I have revised the framework, moved and added, changed the content to reflect what I practice. I would like to share it with you, just click on the Doc title below:

AQUATIC THERAPY PLAN OF CARE

I admit to being descriptive in my SOAP, especially the initial assessment. It is essential to strive to include at least one standardized outcome measure - whether it is an objective range, balance or gait test or a patient-reported outcome measure - it is all about measuring progression and effectiveness. 

Hands-on techniques like WST, BRRM, Watsu, AquaStretch, all have specific holds/descriptors; just make sure you detail any modifications. 

Maybe your client would like a written aquatic exercise program - this is on top of your documentation. It is in layman's language and details how they position themselves, the equipment they need, the depth of water they should be in and the number of reps and sets; be as detailed as possible... What's the intensity of the exercise - maybe the Borg Scale would be a useful device with cue's like "you can talk but not sing" (moderate intensity).  There exists PT software that provides set exercises and some of these offer some aquatic exercise choices. I am not sure they can truly offer the tailored, creative programming that the aquatic environment enables us to prescribe. 

This is an example of a prescription of aquatic exercises for a client:

SAMPLE AQUATIC EXERCISE SHEET for Client1

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