1. Documentation
SOAP Notes

2. 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

3. 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

4. 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?

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

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

8. 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

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

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

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

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