Subjective- detailed information about the history of the injury, chief complaints, signs, and symptoms. Given by the athlete!
Objective - record of test measurements. State the information gained from inspection, palpation, and special tests.
Assessment - State the type and severity of the injury and list problems associated with the injury. Should describe functional deficits. Should be clear and concise. Examples - lack of range of motion, lack of strength, inability to perform....certain functional movements, pair with particular motion or activities
Plan of Care - describe whether the athlete will be referred, treated, or monitored. Describe any rehab procedures as well as the goals of treatment. Goals must be short and long term, should reflect the list of problems from the assessment, be objective and have a time frame. The athlete should be involved with the goal getting and transport should be considered