Documentation SOAP Notes.

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Presentation transcript:

Documentation SOAP Notes

Documenting Injury Evaluation Information ______________________________________ documentation is critical Clear, concise, accurate records is necessary for ________________ 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 ______________________________________ _____________________________________________ _____________________________________________ SOAP notes allow for subjective & objective information, the assessment and a plan to be _________________

SOAP- Subjective History: Attitude, mental condition, and perceived physical state. ___________________________ Pt. states … My knee is grinding, I am dizzy, my ankle hurts, etc My back started to hurt when I was wrestling a teammate in practice The pain is sharp I can’t point my toes to shoot a soccer ball. Every season in XC, my shins hurt I have had 3 concussions before Sitting makes my hip feel worse but laying down makes it feel a little better

SOAP- Objective: Observation: ________________ objective signs. ____________________________ Symmetry Posture and Gait ______________________________________________________________

SOAP- Objective Rule out Fx (fracture) ____________ Swelling Crepitus Muscle spasm Pulse

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

SOAP- Objective ____________________ Sport-Specific Functional Testing Myotomes (_________________________) Reflexes Peripheral Nerve Testing Sport-Specific Functional Testing ________________________________________

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 _____________________ Damaged Structures Involved ____________________ Progress Notes This is a ___________________ diagnose. ATC’s can not officially diagnose injuries. Ex. 1st degree inversion ankle sprain, TTP at ATF

SOAP- Plan ________________ treatment given Frequency and duration of treatments and modalities and evaluation On-going patient education _________________________ Ex. Pt. sent home. F/u with MD prior to RTP. RTP with – sx of concussion. Met with mom and gave concussion education material. F/u in ER is HA worsens, difficulty staying awake, or becomes unaware of where they are. F/u with ATC tomorrow after school.