SOAP Notes and Documentation in Physical Therapy

These flashcards cover essential terminology and concepts related to SOAP notes and documentation practices in physical therapy, aiding in exam preparation.

SOAP Notes

A method of documentation that includes Subjective, Objective, Assessment, and Plan.

Subjective

Patient-reported information that includes their feelings, pain levels, and descriptions of their condition.

Objective

Observable and measurable data collected during a patient’s evaluation and treatment.

Assessment

Clinician's professional interpretation of the subjective and objective data.

Plan

The proposed course of action based on the assessment and goals for patient treatment.

TKA

Total Knee Arthroplasty, commonly referred to as knee replacement.

Patient Consent

The process of obtaining a patient’s permission before conducting treatment.

Active Range of Motion (AROM)

Movement performed by a patient independently without assistance.

Passive Range of Motion (PROM)

Movement of a joint performed by an external force without the patient's effort.

Prioritization in Documentation

The practice of focusing on the most relevant information for clarity in patient notes.

Pain Scale

A measurement tool used by patients to describe the severity of their pain, often rated from 0 to 10.

Informed Consent

Process in which the patient understands and agrees to the treatment plan.

Goals

Specific objectives set to measure the patient's progress in therapy.