Documentation SOAP Notes

Documenting Injury Evaluation Information Complete and accurate documentation is critical Clear, concise, accurate records is necessary for third party billing While cumbersome and time consuming, athletic trainer must be proficient and be able to generate accurate records based on the evaluation performed

SOAP Notes Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans SOAP notes allow for subjective & objective information, the assessment and a plan to be implemented

SOAP- Subjective History: Attitude, mental condition, and perceived physical state. Stated by the athlete. Primary Complaint Mechanism of Injury Characteristics of the Symptoms Limitations Past History Type of pain? What makes it better? Worse?

SOAP- Objective: Observation: Measurable objective signs. Appearance Symmetry General Motor Function Posture and Gait Deformity, swelling, discoloration, scars, and general skin condition

SOAP- Objective Rule out FX (fracture) Cutaneous Sens. Skin temperature Pulse Swelling Point tenderness Crepitus Deformity Muscle spasm

SOAP- Objective Functional Tests Stress Tests Active Range of Motion (AROM) Passive Range of Motion (PROM) Resisted Manual Muscle Testing (RROM) Stress Tests Ligamentous Instability Tests Special Tests

SOAP- Objective Neurologic Tests Sport-Specific Functional Testing Dermatomes Myotomes Reflexes Peripheral Nerve Testing Sport-Specific Functional Testing Proprioception and Motor Coordination

SOAP- Objective Sport-Specific Skill Performance Throw the football, baseball, softball, javelin... Kick the soccer ball, football, opponent…

SOAP- Assessment Analyze and assess the individual’s status and prognosis Suspected injury Site Damaged Structures Involved Severity of Injury Progress Notes

SOAP- Plan Immediate treatment given Frequency and duration of treatments and modalities and evaluation On-going patient education Criteria for discharge/return to play