1. Writing SOAP Notes

2. 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

3. 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

4. State Requirements Oregon:
“Athletic trainers 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.”

5. 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

6. 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

7. What does SOAP stand for?
S = Subjective
O = Objective
A = Assessment
P = Plan

8. 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)

9. 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, night, in a.m.
Pain worse during or after activity
Limitations from pain
What aggravates & alleviates pain
Meds:
All:

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

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

12. 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

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

14. 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)

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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. HIPS/HOPS
History
Observation/Inspection
Palpation
Special Tests