Chapter 2 + 3 + Soap Note Documentation

Soap note documentation is also for other _______

providers

What are the purposes of documentation?

-Support Dx and Tx

-Justifies decisions

-Communication

-Protects legal interests

-Monitor patient progress

-Provides data for research

-Supports reimbursement

Define SOAPE

-Subjective

-Objective

-Assessment

-Plan

-Education

Our education box includes

-additional comments

-home-based therapy tasks 

General tips for writing SOAP notes:

-use active voice

-report strengths and weaknesses

In active voice, the _____ does the action

client

What does the subjective include?

-demeanor

-reported medical info

-overall impressions

-reported info

What does the objective include?

-assistance

-goals

-activities

-reinforcement

-data

What does the assessment include?

-efficacy/inefficacy

-compare progress

-clinical hypothesis

-analyze

What does the plan include?

-Recommendations

-Course of treatment

-Continued Services

-Follow-Up