SOAP Notes

What does SOAP stand for

Subjective

Objective

Assessment

Plan

what is the most common method for documenting injuries/illnesses

SOAP

What are the 3 types/times of SOAP notes

Initial

Progress

Discharge

Initial

Written after the patients initial evaluation

Longest subjective part

Progress

Written periodically reporting the results of reassessment

More detailed

Shorter subjective

Discharge

Written at time treatment of therapy ends

What is the order of smallest to largest type of SOAP notes

Progress

Discharge

Initial

Subjective

How the patient explains their problem or symptoms. Perceived only by patient.

When does observation start

as soon as you see the patient

What does SAMPLE history stand for

signs and symptoms of

Allergies

Medication

Past pertinent history

Last oral intake

Events leading up to most recent symptoms

Signs

you can see and measure

Symptoms

You can’t see or measure

What does OPQRST stand for

Onset

Provocation

Quality

Radiating

Severity

Treatment

Onset

How rapid or acute something happened

provocation

What makes it worse/better

Quality

describe pain and symptoms

Radiating

does it hurt elsewhere

Objective

measurable and observable data

What are some examples of objective info you could take

presentation/initial observations

Visual inspection/palpation

Range of motion

Strength testing

Special tests

Neurological and vascular(blood flow)

What are the soft tissue injuries to look for? DCAP-BTLS

Deformities

Contusion

Abrasions

Punctures/penetrations

Burns

Tenderness

Lacerations

Swelling

Adema(tissue)

swelling

Assessment

What is the problem

Diagnosis

Identification of an illness or other problem by examination of signs and symptoms

Differential diagnosis

Process of determining between 2 or more conditions which share similar signs or symptoms

What are some examples of signs or symptoms with multiple causes

chest pain

Headaches

Plan

what we do about the problem

What are the parts of the plan

short term

Long term

Problem list

Problem list

findings that aren’t WNL and can be influenced by treatment or therapy

Figure out which problem is most important

List treatment or therapy in priority order

Short term

couple of days/ treatment sessions

Based on long term

Long term

week, month, year or longer

Can be revised