Writing SOAP Writing SOAP NotesNotes

SOAP NotesSOAP Notes

A format/style of documentation in A format/style of documentation in healthcarehealthcare Any document can be written in this style Any document can be written in this style

Originally designed for Osteopathic Originally designed for Osteopathic medicinemedicine

Designed to achieve a more structured Designed to achieve a more structured evaluationevaluation Includes a thorough hx & physical examIncludes a thorough hx & physical exam Allowed for more accurate DxAllowed for more accurate Dx

Organized, concise documentOrganized, concise document Utilizes medical abbreviations Utilizes medical abbreviations

Purpose of SOAP NotesPurpose of SOAP Notes

Liability:Liability: legal document legal document Communication:Communication: method to communicate method to communicate

w/ other healthcare professionals and/or w/ other healthcare professionals and/or your staffyour staff

Insurance:Insurance: third party reimbursement third party reimbursement Progress Report:Progress Report: review report to decide review report to decide

if Tx is effectiveif Tx is effective Research:Research: to collect injury data statistics to collect injury data statistics Education:Education: to improve quality of care to improve quality of care

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.”

SOAP NotesSOAP Notes

Write it as soon as possible before it Write it as soon as possible before it fades from your memoryfades from your memory May have to take notes during the May have to take notes during the

evaluation initiallyevaluation initially Notes should organized & Notes should organized &

chronologicalchronological Use subheadings Use subheadings Underline headingsUnderline headings

Notes should include past & present Notes should include past & present examinations, tests, Tx, & outcomesexaminations, tests, Tx, & outcomes

SOAP NotesSOAP 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

What does SOAP stand What does SOAP stand for?for?

S S = Subjective= Subjective OO = Objective = Objective AA = Assessment = Assessment PP = Plan = Plan

SubjectiveSubjective Information obtained from PtInformation obtained from Pt Very important to get a good HxVery important to get a good Hx

The background of the injury will often give The background of the injury will often give you the answeryou the answer

Includes:Includes: Hx: pertinent background informationHx: pertinent background information MOI or HPI: how, what, when, where of the MOI or HPI: how, what, when, where of the

injuryinjury C/O: Pt’s sx including description of pain C/O: Pt’s sx including description of pain Meds: current medications being taken (Rx, Meds: current medications being taken (Rx,

OTC, sup)OTC, sup) All: any allergiesAll: any allergies

SubjectiveSubjective Hx: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:

Unusual Unusual sounds/sensationssounds/sensations

Clicking/Locking:Clicking/Locking: Meniscus/labral injuryMeniscus/labral injury

Pop:Pop: Ligament injuryLigament injury Patellar/GH dislocationPatellar/GH dislocation Muscle tearMuscle tear

Snapping/Popping:Snapping/Popping: TendonitisTendonitis BursitisBursitis

Pulling: Pulling: Muscle strainMuscle strain

ObjectiveObjective Physical findings:Physical findings:

Everything you observe, palpate, or testEverything you observe, palpate, or test Typically measurable/repeatableTypically measurable/repeatable Includes: Includes:

ObservationObservation InspectionInspection Special TestsSpecial Tests NeurovascularNeurovascular ROMROM MMTMMT

ObjectiveObjective Begins the moment you first see themBegins the moment you first see them

Assess the individual’s state of Assess the individual’s state of consciousness & body language consciousness & body language May indicate pain, disability, fracture, May indicate pain, disability, fracture,

dislocation, or other conditionsdislocation, or other conditions Note their general posture, willingness & Note their general posture, willingness &

ability to moveability to move When you start your exam:When you start your exam:

Check bilaterally & think outside the box!Check bilaterally & think outside the box! Don’t get caught up in the specific areaDon’t get caught up in the specific area

ObservationObservation ALWAYSALWAYS compare bilaterally compare bilaterally Gait & postureGait & posture Obvious deformityObvious deformity BleedingBleeding Mental alertness – state of Mental alertness – state of

consciousnessconsciousness Discoloration/EcchymosisDiscoloration/Ecchymosis SwellingSwelling Atrophy/Hypertrophy Atrophy/Hypertrophy Symmetry Symmetry ScarsScars SkinSkin

ObjectiveObjective Palpation: Palpation:

DeformityDeformity Point tenderness Point tenderness TemperatureTemperature CrepitusCrepitus

Special Tests:Special Tests: (+/-) (+/-) Fx testsFx tests Specific tests for body partSpecific tests for body part Functional testsFunctional tests

Fracture TestsFracture Tests

Squeeze/CompressionSqueeze/Compression TapTap UltrasoundUltrasound Tuning ForkTuning Fork

*Positive Sign: Localized, *Positive Sign: Localized, Shooting PainShooting Pain

ObjectiveObjective (NV) Neurovascular:(NV) Neurovascular: (G or P, +/-, (G or P, +/-,

WNL/N)WNL/N) Myotomes - StrengthMyotomes - Strength Dermatomes - SensoryDermatomes - Sensory Skin Temp/ColorSkin Temp/Color Cap refillCap refill Pulse/BPPulse/BP Reflexes (superficial & deep tendon)Reflexes (superficial & deep tendon)

ROM:ROM: (in degrees) (in degrees) AROM/PROMAROM/PROM End feelEnd feel

MMT/RROM:MMT/RROM: (out of 5) (out of 5) Strength testsStrength tests Break testsBreak tests

MMT ScaleMMT Scale 0/5: no contraction0/5: no contraction 1/5: muscle flicker, but no movement1/5: muscle flicker, but no movement 2/5: movement possible, but not against 2/5: movement possible, but not against

gravitygravity 3/5: movement possible against gravity, but 3/5: movement possible against gravity, but

not against resistance by the examiner not against resistance by the examiner 4/5: movement possible against some 4/5: movement possible against some

resistance by the examiner resistance by the examiner Can be subdivided further into 4Can be subdivided further into 4––/5, 4/5, and 4/5, 4/5, and 4++/5/5

5/5: normal strength5/5: normal strength

AssessmentAssessment

Your professional opinion of the type of Your professional opinion of the type of injury/illness injury/illness

Based off the subjective & objective Based off the subjective & objective portions of the examportions of the exam

Include:Include: Anatomical locationAnatomical location SeveritySeverity DescriptionDescription

The exact injury/illness may not be knownThe exact injury/illness may not be known Exp: Possible 2° L ATFL sprainExp: Possible 2° L ATFL sprain

PlanPlan Tx the patient will receive that dayTx the patient will receive that day

Ice, splint, crutchesIce, splint, crutches Plan for further assessment or Plan for further assessment or

reassessmentreassessment Patient/Family education: Home Patient/Family education: Home

instructionsinstructions i.e.: Concussion Take Home Instructionsi.e.: Concussion Take Home Instructions

ReferralReferral Short & Long term goals: need to be Short & Long term goals: need to be

measurable measurable Expected functional outcomes Expected functional outcomes Equipment needsEquipment needs Plans for discharge/RTPPlans for discharge/RTP

Plan – Plan – Treatment/TherapyTreatment/Therapy

Frequency Frequency LocationLocation DurationDuration TypeType ProgressionProgression

Example of generic plan: Pt will be seen TIW x 6 weeks to include

TE & modalities as needed

Plan - Short-term GoalsPlan - Short-term Goals

Goals that will allow Pt to achieve long-term Goals that will allow Pt to achieve long-term goalsgoals

Record specific rehab ex’sRecord specific rehab ex’s Record any modalities used & exact Record any modalities used & exact

parameters usedparameters used Day to day or weeksDay to day or weeks

Example: Example: Increase R shoulder flexion to 145Increase R shoulder flexion to 145oo (from 125 (from 125oo), ),

increase function so Pt can comb their hair c R increase function so Pt can comb their hair c R hand in 7 days. hand in 7 days.

List specific stretching & functional exercises List specific stretching & functional exercises

Plan - Long-term GoalsPlan - Long-term Goals

Expected outcomesExpected outcomes Includes:Includes:

What is the outcomeWhat is the outcome What will it take to achieve that outcomeWhat will it take to achieve that outcome

Include measurements and specific interventions for Include measurements and specific interventions for each goal each goal

What conditions must exist for a good outcome What conditions must exist for a good outcome Example: Example:

Return to full strength (5/5 from 4/5), full Return to full strength (5/5 from 4/5), full ROM (170ROM (170oo from 145 from 145oo), return to volleyball), return to volleyball

List specific strength ex’s, stretches, & List specific strength ex’s, stretches, & sport specific activitiessport specific activities

Progress NoteProgress 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

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

Progress Note - ObjectiveProgress 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

HIPS/HOPSHIPS/HOPS

HistoryHistory

Observation/InspectionObservation/Inspection

PalpationPalpation

Special TestsSpecial Tests