Standard 10 Medical Therapeutics S.O.A.P. Notes

Standard 10 Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through: a. History and Physical including but not limited to: family, environmental, social, and mental history b. Brief Head to Toe Assessment noting normal vs. abnormal findings c. Vital Signs Assessment (VS) d. Height/weight, BMI /Calculation e. Specimen Collection

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 (history) & physical exam Allowed for more accurate Dx (diagnosis) 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 (treatment) is effective Research: to collect injury data statistics Education: to improve quality of care

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, OT, RN 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 A = Assessment P = Plan

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

Physiological Responses Term Definition Acute physiological response An immediate change (increase or decrease) in one or more of the bodies systems in response to a stimuli   Chronic physiological adaptations Changes to one or more of the bodies systems as result of long term consistent stimulus, such as exercise 

Subjective Hx: MOI: C/O: (or chief complaints - CC) Meds: All: PSHx (past surgical history), PFHx (past family history), 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: (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:

Possible Questions: How did this injury occur? Where do you feel pain? When did the injury occur/ When did it start hurting? Are you having trouble walking/writing/ getting dressed/etc.? Have you injured this area before? Did you hear or feel anything pop or tear?

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 (range of motion) MMT (manual muscle testing)

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 (fracture) 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: Myotomes - Strength Dermatomes - Sensory Skin Temp/Color Cap refill Pulse/BP Reflexes (superficial & deep tendon) ROM: (in degrees) AROM/PROM (active ROM/passive ROM) End feel MMT/RROM: (resistive ROM) Strength tests (0-5 scale) Break tests (0-5 scale) 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 (return to play/participation)

Plan – Treatment/Therapy Frequency Location Duration Type Progression Example of generic plan: Pt will be seen TIW (3x a week) x 6 weeks to include TE (therapeutic exercises) & 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

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

HIPS/HOPS History Observation/Inspection Palpation Special Tests