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Writing SOAP Notes
SOAP Notes
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A format/style of documentation in healthcare
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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
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Organized, concise document
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Utilizes medical abbreviations
Purpose of SOAP Notes
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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
State Requirements
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Oregon:
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“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 Notes
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Write it as soon as possible before it fades from
your memory
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May have to take notes during the evaluation initially
Notes should organized & chronological
Use subheadings
 Underline headings
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Notes should include past & present
examinations, tests, Tx, & outcomes
SOAP Notes
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Notes must be legible!
Never use “I” refer to your professional title
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Use quotes whenever possible
Do not use hyphens
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i.e. ATC, PT
Confused w/ minus signs
Use black or blue ink only
Sign all evals and progress notes
What does SOAP stand for?
S
= Subjective
 O = Objective
 A = Assessment
 P = Plan
Subjective
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Information obtained from Pt
Very important to get a good Hx
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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
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Subjective
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Hx:
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MOI:
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PSHx, PFHx, Past Tx, social hx, prev injuries, change in activity,
Any unusual noises/sensations heard/felt
Onset of injury: acute or gradual (chronic)
C/O: complains of (or chief complaints - CC)
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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
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Limitations from pain
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What aggravates & alleviates pain
Meds:
All:
Unusual sounds/sensations
 Clicking/Locking:
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Meniscus/labral injury
 Pop:
Ligament injury
 Patellar/GH dislocation
 Muscle tear
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 Snapping/Popping:
Tendonitis
 Bursitis
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 Pulling:
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Muscle strain
Objective
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Physical findings:
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Everything you observe, palpate, or test
Typically measurable/repeatable
Includes:
Observation
 Inspection
 Special Tests
 Neurovascular
 ROM
 MMT
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Objective
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Begins the moment you first see them
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Assess the individual’s state of consciousness & body
language
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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
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Observation
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ALWAYS compare bilaterally
Gait & posture
Obvious deformity
Bleeding
Mental alertness – state of consciousness
Discoloration/Ecchymosis
Swelling
Atrophy/Hypertrophy
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Symmetry
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Scars
Skin
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Objective
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Palpation:
 Deformity
 Point tenderness
 Temperature
 Crepitus
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Special Tests: (+/-)
 Fx tests
 Specific tests for body part
 Functional tests
Fracture Tests
Squeeze/Compression
 Tap
 Ultrasound
 Tuning Fork
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*Positive Sign: Localized, Shooting Pain
Objective
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(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
MMT Scale
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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
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Can be subdivided further into 4–/5, 4/5, and 4+/5
5/5: normal strength
Assessment
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Your professional opinion of the type of injury/illness
Based off the subjective & objective portions of the
exam
Include:
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Anatomical location
Severity
Description
The exact injury/illness may not be known
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Exp: Possible 2° L ATFL sprain
Plan
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Tx the patient will receive that day
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Plan for further assessment or reassessment
Patient/Family education: Home instructions
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Ice, splint, crutches
i.e.: Concussion Take Home Instructions
Referral
Short & Long term goals: need to be measurable
Expected functional outcomes
Equipment needs
Plans for discharge/RTP
Plan – Treatment/Therapy
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Frequency
Location
Duration
Type
Progression
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Example of generic plan:
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Pt will be seen TIW x 6 weeks to include TE &
modalities as needed
Plan - Short-term Goals
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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
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Example:
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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
Plan - Long-term Goals
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Expected outcomes
Includes:
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What is the outcome
What will it take to achieve that outcome
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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
Progress Note
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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
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Progress Note - Subjective
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Response to treatment & rehab
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Decreased/increased pain
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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)
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Patient compliance issues c ex’s
Progress Note - Objective
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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
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HIPS/HOPS
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History
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Observation/Inspection
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Palpation
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Special Tests