1. Introduction to SOAP Notes

2. Components Problem S = subjective O = objective A = Assessment
P = Plan

3. Problem (or Diagnosis)
Medical diagnosis (e.g. adhesive capsulitis) or problem (e.g. frozen shoulder)
Problem includes (as applicable):
Recent or past surgeries
Past conditions or diseases
Present conditions or diseases
Medical test results
Referral mechanism

4. Examples
Dx: (L) hemiplegia resulting from craniotomy for removal of tumor on Hx of htn. Referring physician: Dr. Alexad.
58-yr-old ♂ w/ (L) BK amputation on , 20 PVD. Hx of diabetes. Referring physician: Dr. Ollandern.

5. Subjective
Things the patient (or significant other) tells us about his/her:
Condition/chief complaint
Functional status/activity level
Cultural and religious beliefs
Employment status
Living environment
General health status
Social/health habits
Family health history

6. Subjective (cont’d) Medical/surgical history Medications
Growth & development
other clinical tests
Response to treatment intervention
Goals
Or – anything else relevant and significant to the patient’s case or present condition

7. Subjective: Things to consider
Use of the term “patient”
Organization; concise
Verbs: states, describes, denies, indicates, c/o
Quoting the patient verbatim
To illustrate confusion or memory loss
To illustrate denial
To describe pain

8. Subjective: Example 1. Information from the patient
S: Current condition: c/o pain (R) ankle when (R) ankle is in dependent position. Denies any other pain or dizziness. States fell at home and felt (R) ankle “pop.” Living environment: Describes 3 steps w/o a handrail at entrance to the home. Denies use of crutches PTA. Social/health habits: States played basketball 3x/wk PTA. Patient goals: Pt’s goal is to play basketball again.

9. Subjective: Example 2. Information from the family
S: (All of the following information was taken from the pt’s daughter. Pt. is unable to verbalize 2° to aphasia.) Functional status/activity level: Pt amb indep PTA….

10. Subjective: Example 3. Combining
S: Current condition: Pt c/o SOB immediately post examination … Medical/surgical hx: Husband states pt has hx COPD for 10 yrs …

11. Objective Things we find during the examination: Systems review
Tests and measures
Functional skills
Medical history when taken from the medical record

12. Objective: Things to Consider
Organize and categorize
Use headings, caps & underlining
Use tables or charts
Use flow sheets
Be specific
State the affected anatomy
State information in measurable terms
State type (e.g. transfer to where from where?)

13. Objective: Example
O: HISTORY: CHF, COPD SYSTEMS REVIEW: Cardiovascular/ pulomonary system: BP 140/85. HR 90. RR 20. Integumentary system: skin thin & fragile bilat LEs. Musculoskeletal system: gross symmetry impaired in LEs standing. Neuromuscular system: Gait unimpaired. Transfers impaired. Communication: Age appropriate and unimpaired. Affect: emotional/behavioral responses unimpaired. Cognition: level of consciousness unimpaired. Orientation to person, place and time impaired … TESTS AND MEASURES: AROM: WNL t/o UEs and LEs except 1200 (L) shoulder flexion. Strength: 5/5 t/o UEs …

14. Assessment Your professional opinion PT Diagnosis
Specific practice pattern or patterns (primary and secondary)
Inconsistencies
Further testing needed
Consultations and/or referrals w/ other practitioner(s) needed

15. Assessment (cont’d)
Prognosis: predict the level of improvement in function and the amount of time needed to reach that level.
Consider:
Living environment
Patient’s condition prior to onset
Concurrent illnesses or medical conditions (co-morbidities)

16. Assessment: Example
A: DIAGNOSIS: Pt’s ↓ ROM & strength (L) wrist cause pt difficulty in ADLs such as eating and writing. Pt’s work involves typing over 50% of the time and pt is unable to type w/o pain. Practice pattern: Musculoskeletal G: Impaired joint mobility, muscle performance and ROM associated w/ fracture PROGNOSIS: Pt. has good rehab potential; will progress well with PT and return to work w/ full ROM and strength and w/o pain in six weeks.

17. Plan Where do you want to go and how are you going to get there?
Goals:
Long-term
Short-term
Intervention
Discharge plans

18. Plan: Long-Term Goals Expected outcomes
Functional; behaviorally stated
Includes:
Who (who will exhibit the behavior)
Behavior (what actions will the person exhibit)
Conditions (what is needed for the person to perform the behavior)
Degree (a measure by which you will determine success)
Example:
P: Long-term goal: “Indep amb (behavior) w/ a walker (condition) FWB (L) LE (another condition) for at least 150 ft x 2 (degree) on level surfaces & on 1 step elevation (more conditions) within 1 mo (degree) to allow patient (who) to amb around her home (function).”

19. Plan: Short-Term Goals
Anticipated goals
The interim steps needed to achieve the long-term goals
Also include the
Who
Behavior
Condition
Degree

20. Plan: Short-Term Goals - Examples
Examples showing pt progress toward long-term goal of “Indep amb w/ a walker FWB (L) LE for at least 150 ft x 2 on level surfaces & on 1 step elevation within 1 mo to allow patient to am around her home”:
Short-term goal: Pt will amb 30 ft x 2 in // bars 10% PWB (L) LE within 3 days w/ mod + 1 assist
Short-term goal: Pt will amb w/ walker 50 ft x 2 10% PWB (L) LE within 1 week w/ min +1 assist

21. Plan: Interventions Must include: May also include:
Frequency (per day or per week) that pt will be seen
Interventions
May also include:
Location of treatment (bedside, in dept., at home)
Treatment progression
Plan for further assessment or reassessment
Plans for discharge
Patient & family education
Equipment needs or equipment ordered
Referrals to other services

22. Plan: Interventions - Example
Intervention plan: BID in dept.: amb training w/ a walker beginning w/ 50% PWB (L) LE & progressing wt. bearing & distance as tolerated; transfer training; pt will be given written and verbal instructions in exercise program to be performed in his room (attached); AAROM progressing to AROM exercises (L) knee emphasizing quadriceps functioning.

23. Note Writing and the Process of Clinical Decision-Making
SOAP Note
Patient/Client Management Process
Patient/Client Management Note
Problem
Subjective
Objective
EXAMINATION
History
Systems Review
Tests & Measures
Assessment (includes Diagnosis and Prognosis)
EVALUATION
Diagnosis
Prognosis
Plan of Care (Expected Outcomes, Anticipated Goals and Interventions, including patient education)
PLAN OF CARE
Expected Outcomes
Anticipated Goals
Interventions, including patient education
OUTCOMES