Writing SOAP Notes

1. Writing SOAP Notes

2. Standards Evaluate factors that contribute to effective patient/client communication, demonstrating sensitivity to barriers, cultural differences, and special needs individuals. Apply effective practices within a lab/clinical setting. Describe evidence-based techniques and procedures for evaluating common medical conditions, disabilities, and injuries. Discuss at minimum the procedures surrounding inspection/observation, palpation, testing of flexibility, endurance, and strength, special evaluation techniques, and neurological testing. Using appropriate medical language and terminology, interpret objective and subjective data obtained in standard 13 in developing an appropriate therapeutic treatment plan for a given injury, disease, or disorder, including determination of goals and objectives in order to return the patient to maximum level of performance based on level of functional outcomes.

3. Objective To learn how to write, organize, and compile information in an effective manner which will be effective in communicating with other medical professionals. To learn to how differentiate between medical terminology needed for proper documentation and medical terminology needed to communicate with our patients

4. 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

5. 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

6. State Requirements “…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.”

7. 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

8. 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

9. What does SOAP stand for? • S = Subjective • O = Objective/Observe • A = Assessment • P = Plan

10. 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

11. Subjective • Hx: • 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, constant, @ night, in a.m. • Pain worse during or after activity • Limitations from pain • What aggravates & alleviates pain • Meds: • All:

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

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

14. 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

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

16. Objective • Palpation: • Deformity • Point tenderness • Temperature • Crepitus • Special Tests: (+/-) • Fx tests • Specific tests for body part • Functional tests

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Plan - Long-term Goals • Expected outcomes • Includes: • 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

25. HIPS/HOPS vs SOAP • History • Observation/Inspection • Palpation • Special Tests

26. Progress Note When would we write a progress note

27. 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

28. 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

29. 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

30. Progress Note- Assessment • Does the assessment ever change? • NO!