Writing SOAP Notes

Standards Evaluate factors that contribute to effective patient/client communication, demonstrating sensitivity to barriers, cultural differences, and special needs individuals. Apply effective practices within a lab/clinical setting. Describe evidence-based techniques and procedures for evaluating common medical conditions, disabilities, and injuries. Discuss at minimum the procedures surrounding inspection/observation, palpation, testing of flexibility, endurance, and strength, special evaluation techniques, and neurological testing. Using appropriate medical language and terminology, interpret objective and subjective data obtained in standard 13 in developing an appropriate therapeutic treatment plan for a given injury, disease, or disorder, including determination of goals and objectives in order to return the patient to maximum level of performance based on level of functional outcomes.

Objective To learn how to write, organize, and compile information in an effective manner which will be effective in communicating with other medical professionals. To learn to how differentiate between medical terminology needed for proper documentation and medical terminology needed to communicate with our patients

SOAP Notes A format/style of documentation in healthcare Any document can be written in this style Originally designed for Osteopathic medicine Designed to achieve a more structured evaluation Includes a thorough hx & physical exam Allowed for more accurate Dx Organized, concise document Utilizes medical abbreviations

Purpose of SOAP Notes Liability: legal document Communication: method to communicate w/ other healthcare professionals and/or your staff Insurance: third party reimbursement Progress Report: review report to decide if Tx is effective Research: to collect injury data statistics Education: to improve quality of care

State Requirements “…are required to accept responsibility for recording details of the athlete's health status and include details of the injured athlete's medical history, including: name; address; legal guardian if a minor; referral source; all assessments & test results, by date of service provided; treatment plan and estimated length for recovery; record of all methods used; results achieved; any changes in the treatment plan; record of the date the treatment plan is concluded and provide a summary; sign and date each entry.”

SOAP Notes Write it as soon as possible before it fades from your memory May have to take notes during the evaluation initially Notes should organized & chronological Use subheadings Underline headings Notes should include past & present examinations, tests, Tx, & outcomes

SOAP Notes Notes must be legible! Never use “I” refer to your professional title i.e. ATC, PT Use quotes whenever possible Do not use hyphens Confused w/ minus signs Use black or blue ink only Sign all evals and progress notes

What does SOAP stand for? S = Subjective O = Objective/Observe A = Assessment P = Plan

Subjective Information obtained from Pt Very important to get a good Hx The background of the injury will often give you the answer Includes: Hx: pertinent background information MOI or HPI: how, what, when, where of the injury C/O: Pt’s sx including description of pain Meds: current medications being taken (Rx, OTC, sup) All: any allergies HPI (history of present injury/illness)

Subjective Hx: MOI: C/O: complains of (or chief complaints - CC) Meds: PSHx, PFHx, Past Tx, social hx, prev injuries, change in activity, MOI: Any unusual noises/sensations heard/felt Onset of injury: acute or gradual (chronic) C/O: complains of (or chief complaints - CC) Pain scale (1-10) Location, severity, & type of pain Burning, stinging, sharp, dull, deep, nagging, radiating, constant, @ night, in a.m. Pain worse during or after activity Limitations from pain What aggravates & alleviates pain Meds: All:

Unusual sounds/sensations Clicking/Locking: Meniscus/labral injury Pop: Ligament injury Patellar/GH dislocation Muscle tear Snapping/Popping: Tendonitis Bursitis Pulling: Muscle strain

Objective Physical findings: Typically measurable/repeatable Includes: Everything you observe, palpate, or test Typically measurable/repeatable Includes: Observation Inspection Special Tests Neurovascular ROM MMT

Objective Begins the moment you first see them Assess the individual’s state of consciousness & body language May indicate pain, disability, fracture, dislocation, or other conditions Note their general posture, willingness & ability to move When you start your exam: Check bilaterally & think outside the box! Don’t get caught up in the specific area

Observation Symmetry ALWAYS compare bilaterally Gait & posture Obvious deformity Bleeding Mental alertness – state of consciousness Discoloration/Ecchymosis Swelling Atrophy/Hypertrophy Symmetry Scars Skin

Objective Palpation: Deformity Point tenderness Temperature Crepitus Special Tests: (+/-) Fx tests Specific tests for body part Functional tests If pain limits them (write down unable to perform due to pain)

Fracture Tests Squeeze/Compression Tap Ultrasound Tuning Fork *Positive Sign: Localized, Shooting Pain

Objective (NV) Neurovascular: (G or P, +/-, WNL/N) Myotomes - Strength Dermatomes - Sensory Skin Temp/Color Cap refill Pulse/BP Reflexes (superficial & deep tendon) ROM: (in degrees) AROM/PROM End feel MMT/RROM: (out of 5) Strength tests Break tests If pain limits them (right down unable to perform due to pain)

MMT Scale 0/5: no contraction 1/5: muscle flicker, but no movement 2/5: movement possible, but not against gravity 3/5: movement possible against gravity, but not against resistance by the examiner 4/5: movement possible against some resistance by the examiner Can be subdivided further into 4–/5, 4/5, and 4+/5 5/5: normal strength

Assessment Your professional opinion of the type of injury/illness Based off the subjective & objective portions of the exam Include: Anatomical location Severity Description The exact injury/illness may not be known Exp: Possible 2° L ATFL sprain

Plan Tx the patient will receive that day Ice, splint, crutches Plan for further assessment or reassessment Patient/Family education: Home instructions i.e.: Concussion Take Home Instructions Referral Short & Long term goals: need to be measurable Expected functional outcomes Equipment needs Plans for discharge/RTP

Plan – Treatment/Therapy Frequency Location Duration Type Progression Example of generic plan: Pt will be seen TIW x 6 weeks to include TE & modalities as needed

Plan - Short-term Goals Goals that will allow Pt to achieve long-term goals Record specific rehab ex’s Record any modalities used & exact parameters used Day to day or weeks Example: Increase R shoulder flexion to 145o (from 125o), increase function so Pt can comb their hair c R hand in 7 days. List specific stretching & functional exercises

Plan - Long-term Goals Expected outcomes Includes: Example: What is the outcome What will it take to achieve that outcome Include measurements and specific interventions for each goal What conditions must exist for a good outcome Example: Return to full strength (5/5 from 4/5), full ROM (170o from 145o), return to volleyball List specific strength ex’s, stretches, & sport specific activities

HIPS/HOPS vs SOAP History Observation/Inspection Palpation Special Tests

Progress Note When would we write a progress note

Progress Note Written after each eval/rehab session Can be performed as SOAP note or as a summary Include response to Tx & type of Tx Progress made towards short-term goals Changes in Tx or goals Important notes: Seen by physician Results of diagnostic tests RTP status

Progress Note - Subjective Response to treatment & rehab Decreased/increased pain Include why: from rehab, standing all day, etc Overall psychological profile (i.e. bored) Reassessing subjective information from previous notes Change in function Change in pain (location, type) Patient compliance issues c ex’s

Progress Note - Objective Tx provided Reassess & compare measures that may have changed Note changes in ROM, strength, functional ability Indicate any changes or special notes for rehab Change in modality parameters Assistance needed/not needed during exercises Added/decreased weight/reps/sets/frequency Added or changed exercises

Progress Note- Assessment Does the assessment ever change? NO!