Standard 10 Medical Therapeutics

1. Standard 10Medical Therapeutics S.O.A.P. Notes

2. Standard 10 Demonstrate an understanding of basic medical terminology in order to monitor patient/client status through: a. History and Physical including but not limited to: family, environmental, social, and mental history b. Brief Head to Toe Assessment noting normal vs. abnormal findings c. Vital Signs Assessment (VS) d. Height/weight, BMI /Calculation e. Specimen Collection

3. 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 (history) & physical exam • Allowed for more accurate Dx (diagnosis) • Organized, concise document • Utilizes medical abbreviations

4. 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 (treatment) is effective Research: to collect injury data statistics Education: to improve quality of care

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, OT, RN • 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 (patient) • Very important to get a good Hx. The background of the injury will often give you the answer • Includes: • Hx: pertinent background information • MOI (mechanism of injury): how, what, when, where of the injury • C/O (complains of): Pt’s sx (symptoms) including description of pain • Meds: current medications being taken (Rx, OTC, sup) • All: any allergies

9. Physiological Responses

10. Subjective • Hx: • PSHx (past surgical history), PFHx (past family history), 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: (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:

11. Possible Questions: • How did this injury occur? • Where do you feel pain? • When did the injury occur/ When did it start hurting? • Are you having trouble walking/writing/ getting dressed/etc.? • Have you injured this area before? • Did you hear or feel anything pop or tear?

12. Unusual sounds/sensations • Clicking/Locking: • Meniscus/labralinjury • 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 (range of motion) • MMT (manual muscle testing)

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 (fracture) 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: • Myotomes - Strength • Dermatomes - Sensory • Skin Temp/Color • Cap refill • Pulse/BP • Reflexes (superficial & deep tendon) • ROM: (in degrees) • AROM/PROM (active ROM/passive ROM) • End feel • MMT/RROM: (resistive ROM) • Strength tests (0-5 scale) • Break tests (0-5 scale)

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 (return to play/participation)

22. Plan – Treatment/Therapy • Frequency • Location • Duration • Type • Progression • Example of generic plan: • Pt will be seen TIW (3x a week) x 6 weeks to include TE (therapeutic exercises) & 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. 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

26. 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

27. 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

28. HIPS/HOPS • History • Observation/Inspection • Palpation • Special Tests