1. Documentation
SOAP Notes

2. 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

3. SOAP Notes
Record keeping can be performed systematically which outlines ______________________________________ _____________________________________________ _____________________________________________
SOAP notes allow for subjective & objective information, the assessment and a plan to be _________________

4. 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

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

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

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

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

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
_____________________
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

12. 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.