1. Examination and Assessment

2. SOAP Notes Subjective Objective Assessment Plan

3. Goals General- remove/reduce problems and return pt to full competition Specific- pain relief, restore mobility & strength For every problem listed, there should be a goal to address it

4. Planning- Goals Goals should have 3 portions Activity to be accomplished- walk 2 flights of stairs Any conditions under which it is to be achieved- without assistive devices Time frame – in one week Short term goals in 2 week increments May have multiple goals in that 2 weeks 1 st goal should include reduction of pain, swelling; increase ROM Long term goal- final goal to be achieved

5. Planning for action Progress and potential Any observations of pt’s performance, deficiencies, issues needing to be addressed, concerns, changes for better or worse, other points Are we progressing as expected? Is pt enthusiastic? Poor trunk stability contributing to poor agility?

6. Plan for treatment Plan includes frequency and duration of treatment Various factors involved Increase ROM Modalities AROM Massage At home exercises Always changing as problems decline and status improves

7. Continued Examination and Assessment When it should be done Before treatment After treatment Periodically throughout Goals always changing based on assessment Some immediate post ex Could they do it correctly? Can they do more weight/higher reps? Assessed next session New pain/swelling Pre-treatment findings determine what will be done that day

8. Graduating from rehabilitation

9. Functional Examination As patient progresses, include more functional activities

10. Documentation After each session, a progress note should be completed SOAP format, but not necessarily as formal Discharge Summary After long term goal met Summarizes Pt. condition at time of discharge Summarizes rehab program and duration If another injury to area occurs, can be quick reference to patient response to certain treatments

11. Activity With your notes from Tuesday’s lab (ROM and Flexibility), write a short discharge summary for your “patient”