SOAP Notes

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5 Terms

1
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What does the subjective section include?

  • Patient’s or caregiver’s self-report of status & response to previous treatments

  • Patient problems

  • Patient goals

2
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What does the objective section include?

  • PT’s objective findings

  • Review of Systems

  • Imaging results

  • Current medications

  • Prior level of function & living conditions

  • Social history

  • Systems Review

  • Tests & Measures (impairments & activity limitations)

3
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What does the assessment section include?

  • Clinical Impression

  • Synthesis of condition, impairments, functional limitations, participation restrictions

  • Functional goals (ABCDE or SMART)

  • Support the need for skilled PT

4
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What does the plan section include?

  • Frequency & duration

  • Planned intervention strategies

  • Patient/caregiver education needed

  • Equipment recommended

  • Referrals recommended

  • Discharge plans

5
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What are some examples of planned intervention strategies used?

  • Gait training, including stair climbing

  • Therapeutic exercise to develop strength & endurance, ROM, & flexibility

  • Therapeutic (dynamic) activities to improve functional performance, direct (one-on-one) with patient

  • Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting/standing activities