How can we help?

You can also find more resources in our Help Center.

63 terms

SOAP Notes

STUDY
PLAY
S
SUBJECTIVE
O
OBJECTIVE
A
ASSESSMENT
P
PLAN
SUBJECTIVE
THIS IS THE ARE YOU WILL USE TO WRITE INFORMATION RELEVANT TO THE PATIENT'S CARE THE HE/SHE, SIGNIFICANT OTHERS, OR FAMILY MEMBERS TELL YOU.
SUBJECTIVE
CURRENT SYSPTOMS
SUBJECTIVE
LEVELS OF PAIN
SUBJECTIVE
RESPONSE TO PREVIOUS TREATMENT
SUBJECTIVE
LIVING SITUTATION
SUBJECTIVE
COMPLIANCE WITH TREATMENT
SUBJECTIVE
EACH TIME THE PATIENT IS SEEN, HE OR SHE SHOULD BE INTERVIEWED AND SUBJECTIVE INFORMATION GATHERED.
SUBJECTIVE
INCLUDE INFORMATION RELEVANT TO TREATMENT THAT WAS NOT INCLUDED IN THE INITIAL PT EVAL. ADDITIONALLY, INFORMATION SHARED BY THE PATIENT RELAYING OUTCOME OF OR REACTIONS TO PREVIOUS TREATMENTS BELONG IN THIS SECTION.
SUBJECTIVE
IT MAY BE EASIEST AND MOST ACCURATE TO DIRECLY QUOTE YOUR PATIENT'S COMMENTS.
SUBJECTIVE
GOOD TERMS TO USE IN THE SECTION ARE EXPRESSES, DESCRIBES, DENIES, STATES, REPORTS, COMPLAINS OF.
SUBJECIVE
WHEN THE INFORMATION IS GAINED FROM SOMEONE OTHER THAN THE PATIENT: tHE FOLLOWING INFORMATION WAS GATHERED FROM PATTY PARENT, THE PATIENT'S MOTHER. KELLY KIDDIE IS 18 MONTHS OLD AND NON-VERBAL.
SUBJECTIVE
INFORMATION GAINED FROM BOTH THE PATIENT AND ANOTHER INDIVIDUAL. MR JONES STATES HE IS HAVING DIFFCULTY WALKING UP THE STAIRS BECAUSE OF HIS ARTHRITIS. mRS. JONES NOTES THAT HER HUSBAND HAS NOT BEEN TAKING HIS ARTHRITIS MEDICATION SINCE LAST WEEK.
SUBJECTIVE
PAIN IS ALSO CONTAINED WITHIN THIS SECTION. THE ONLY RULE IS TO USE A CONSISTENT METHOD GAINING AND DOCUMENTING PAIN.
OBJECTIVE
PAINT A PICTURE OF THE PATIENT
OBJECTIVE
THIS IS A REPORT OF YOUR FINDING FROM TESTING AND WHAT HAPPENED AT PT TODAY.
OBJECTIVE
VITAL SIGN
OBJECTIVE
TREATMENT PROVIDED (ROM, MASSAGE)
OBJECTIVE
PAIN "DURING TREATMENT"
OBJECTIVE
INFORMATION IN THIS SECTION COULD BE REPRODUCED BY A SIMILARLY TRAINED PROFESSIONAL AND SIMILAR RESULTS GARNERED.
OBJECTIVE
RESULTS ARE FROM MEASURABLE TESTS.
OBJECTIVE
WHAT DID YOU DO AT PT TODAY?
OBJECTIVE
HOW MUCH DID YOU DO IT (TIMES, NUMBERS OF REPS)
OBJECTIVE
WHAT PART OF THE BODY WAS IT DONE TO? wHAT TISSUES WERE YOU TARGETING
OBJECTIVE
WHAT WERE THE SETTINGS ON THE MACHING?
OBJECTIVE
WHAT POSITION WAS THE PATIENT IN?
OBJECTIVE
WHAT WAS THE PURPOSE OF YOUR TREATMENT?
OBJECTIVE
DID YOU DO ANYTHING UNIQUE OCCUR THAT OTHERS SHOULD BE AWARE OF?
OBJECTIVE
WHAT WAS THE PATIENT'S RESPONSE TO THE TREATMENT?
OBJECTIVE
INFORMATION GARNERED FROM THE MEDICAL RECORD THAT RELATES TO THE CURRENT PROBLEM?
OBJECTIVE
LINKING DATA FROM THE INITIAL EVAL AND PREVIOUS NOTES TO THE PRESENT NOTE IS HELPFUL TO DETERMINE PROGRESS AS A RESULT OF THE TREATMENT PROCEDURES. (SEE ANKLE ROM MEASUREMENTS FROM INITIAL EVALUATION ON 12-10-08)
OBJECTIVE
RESULTS CAN ALSO BE SEEN BY DOCUMENTING THE PATIENT'S FUNCTIONAL LEVEL
OBJECTIVE
SIMPLY STATING TEST AND MEASURES IS NOT ENOUGH TO GET A FULL UNDERSTANDING OF THE PERFORMANCE OF A SKLL YOU MIGHT ALSO WANT TO INCLUDE: hOW THE FUCTION IS BEING AFFECTED BY THE LIMITATIONS?, WHAT IS THE QUALITY OF MOVEMENT (SLOW, AWKWARD, ETC.), LEVEL OF ASSISTANCE REQUIRED TO COMPLETE THE TASK. wHAT EQUIPMENT IS NEEDED?, qUALIFIERS OF THE DISTANCE/WEIGHT HEIGHT OF SKILLS PERFORMED, ENVIRONMENTAL BARRIERS ENCOUNTERED (CARPET, RAMPS, ETC.)
OBJECTIVE
PATIENT EDUCATION ACTIVITIES PERFORMED/INSTRUCTED ARE INCLUDED HERE.
OBJECTIVE
DOCUMENT YOUR OBSEVATIONS OF THE PATIENT AND HIS/HER RESPONSE TO THE THERAPY. THAT YOU SEE, FEEL, PALPATE, ETC. IS ALL INFORMATION THAT SHOULD BE IN THE NOTE.
OBJECTIVE
DESCRIPTION OF GAIT, BULGING LUMP IN BICEP AREA, REDNESS AROUND A JOINT.
OBJECTIVE
YOU ARE NOT WRITING WHAT YOU DID, BUT RATHER WHAT THE PATIENT DID.
OBJECTIVE
FOLLOWING INSTRUCTION, PATIENT SHOW COMPETENCE IN PREFORMING OF HEP PER INSTRUCTIONS (SEE HAND OUT IN CHART)
ASSESSMENT
YOUR PROFESSIONAL JUDGEMENT.
ASSESSMENT
PATIENT'S RESPONSE TO TREATMENT TODAY.
ASSESSMENT
CHANGES IN VS WITH TREATMENT
ASSESSMENT
ABILITY TO PERFORM EXCERSICES WITH MORE APPROPRIATE TECHNIQUES.
ASSESSMENT
SO WHAT? WHAT YOU WRITE IN THIS SECTION TELLS THE READER WHY PT IS NECESSARY!
ASSESSMENT
WHAT THE PT DOES.
ASSESSMENT
DEVELOPS A PROBLEM LIST TO ASSIST WITH GOAL WRITING.
ASSESSMENT
WRITES PATIENT'S GOALS/DESIRED FUCTIONAL OUTCOMES, BOTH LONG TERM AND SHORT TERM.
ASSESSMENT
WHILE YOU WILL NOT BE WRITING THE GOALS, YOU CAN ASSIST THE PT WITH DETERMINING PATIENT GOALS, MOTING PROGRESS TOWARD THESE GOALS, AND THE NEED FOR POSSIBLE REEVALUATION OF THE GOALS BASED ON THE PATIENT'S RESPONSE TO TREATMENT.
ASSESSMENT
AVOID SAYINT "pt TOLERATED WELL" AS THIS TELLS US NOTHING. THE ONLY TIME THIS MAY BE APPROPRIATE IS WHEN PAIRED WITH OTHER DATA OR IF THE PATIENT HAS NOT TOLERATED OTHER TREATMENTS AND SOMETHING HAS NOW BEEN FOUND THAT HE/SHE WILL TOLERATE.
PLAN
THIS IS A STATEMENT OF WHAT WILL HAPPEN NEXT.
PLAN
WHAT NEEDS TO BE DONE BEFORE OR DURING THE NEXT SESSION
PLAN
REFERRAL TO OTHER SERVICES WOULD BE APPROPRIATE FOR THIS SECTION.
PLAN
FREQUENCY OF THERAPY MUST BE WRITTEN HERE.
PLAN
SOMEWHERE IN THIS SECTION SHOULD BE A STATEMNT OF THE COLLABORATION BETWEEN THE PT AND PTA. THIS MAY INCLUDE: WILL BEGIN AMB TRAINING PER PTGOAL IN INITIAL EVAL. WILL CONSULT WITH PT REGUARDING pt CONTINURED COMPLAINTS OF PAIN DISPITE IMPROVING OBJECTIVE DATA.
PLAN
INCLUDE HOW MANY VISITS ARE LEFT, WHEN DISCHARGE IN ANTICIPATED, ETC. BASED ON INFO FROM INITIAL EVAL AND CONSULTATION WITH PT.
PLAN
USULLY WRITTEN IN FUTURE TENSE...WILL IS A COMMON VERB.
NARRATIVE DOCUMENTATION
TF YOU ARE PROVIDING DOCUMENTATION WITHOUT USING A SPECIFIED FORMAT, IT IS IMPORTANT TO INCLUD ALL NESSARY COMPONENTS.
S
A SUBJECTIVE REPORT FROM PATIENT.
O
A REPORT OF YOUR FINDING FROM THE SESSION REGARDING OBJECTIVE DATA.
A
WHAT DOES EVERYTHING YOU'VE SAID SO FAR MEAN WITH RESPECT TO THE PATIENT'S FUCTIONAL ABILITIES?
P
WHAT WILL HAPPEN NEXT?