SOAP-Note

SOAP-Note

• S–subjective (individual)
• O – objective
• A – assessment
• P – plan
• Note

S – subjective part

Anamnesis

• Individual anamnesis (individual, specific): present complaints: previous - new; connections; does it confuse the patient; needs help; general symptoms: fever, weakness, loss of appetite; previous illness- connections; surgery; trauma; allergies

• Family history: accumulation in family; inheritance e.g. obesity, hypertension, diabetes

• Environmental anamnesis: where the patient lives; type of house; mode of transport, may it affect treatment; how the house is built (accessibility); elevator– stairs

• Social history: how supported the person is e.g. homeless, married, single; social network; living conditions (lifestyle; stress; workload; cooperation; willingness)

• Occupational history: active worker; student; retired (do symptoms affect work; sedentary work; physical-mental work; equipment); how adaptable is the workplace

• Sports habits: competitive-hobby sports (warm-up + appropriate equipment); previous injuries/competitive injuries

ΣWhat are the connections with the current complaints? How do they affect treatment?

S – subjective part

Pain

Localization is important:
• Musculoskeletal - other (internal) symptoms
• Spinal pain - limb pain (symptoms)
• Intraarticular (cartilage problem) - extraarticular (nerve + muscle problem)

Forms:
• Mechanical - injury; inflammatory - swelling, red skin, warm, dysfunction, pressure sensitive

Cause:
• Articular; muscular; radicular; neurological

Type:
• Localized- radiating; superficial- deep; continuous - periodic

Characteristic:
• Stabbing; burning; numbing; dull; splitting; streaky - neurological problem; throbbing; sharp; gagging; forceful; shooting- neurological problem

Provocativeness:
• During movement; during loading (cartilage problem); during rest; in different body position (neurological problem- stretching); during changing a position; cold- hot → increase/decrease the complaint

Daily appearance:
• Morning; daytime; evening; night (when the symptom is the strongest)

O – objective part

Body/personal characteristics:
• Body weight
• Height • Hip-belly circumference
• Body proportions

Function:
• GM (grand motor)
• FM (manipulations) • ADL (activities of daily living) • OM (oral motor, mimicking)

Holding:
• Static
• Dynamic (during movement)

O – objective part

Steps of objective assessment:

• Inspection
• Palpation
• Active movement assessment
• Passive movement assessment
• Isometric resistance assessment
• Muscle strength assessment
• Special tests
• Other tests: percussion; auscultation; laboratory tests; X-rays

O – objective part

Inspection

• It starts when the patient enters, does he/she use an assistive device (cane; walking frame; does he/she use somebody's help)

• Inspection of the bony structures & soft tissues (muscles; skin; oedema, scar, etc.)

• Looking for differences from physiological

• ALWAYS NEED TO KNOW: what is physiological; what is physiologically visible

• Forms of inspection:
Static: from front; from back; from side (both sides viewed- compared)
Dynamic: during different movements, usually done in standing, but can also be done in sitting/lying position

• Posture (from all directions; neutral- anatomical; mid-line/gravity line); symmetry asymmetry (right/left side); neck- head position; shoulder girdle- pelvis position; position of limbs in relation to trunk/each other; curvatures of spine; lower limb axes; foot arch structure; compensatory movements.

O – objective part

Palpation

NOT to be performed through clothes

• Palpation of bony structures
• Palpation of soft tissues (e.g.: muscles)
• Palpation of other structures (e.g.: skin turgor- quality; mobility; temperature; elasticity)

Aim:
• Clarify the differences detected during the inspection
• Pressure sensitivity, bony deformities, muscle tone are observed
• Bone continuities; calluses (palpation of bony formations: with the tip of the index or middle finger or both, continuously)
• Muscles are palpated during contraction (isometric muscle contraction- resistance- no displacement/movement)
• Muscle weakness; muscle tone abnormalities (e.g.: spastic, rigid, flaccid)
• Palpation of tendons, ligaments: tensed- perpendicular to them; back and forth, transversely, giving compression, passive stretching
• Detect any unusual sensations in the patient (dysaesthesia, hyperaesthesia, anaesthesia)

Palpation is continuous; in the case of muscle, it lasts from origin to insertion! The area to be examined is placed in a relaxed position, except for ligaments and muscles.

O – objective part

Active movement assessment

Determination of the range of motion of a given joint

To be known:
• The Function of the tested joint; its movements in the given plane; the physiological ROM.
• We will check the harmony and quality of the movement.
• Assess the patient's cooperation, state of consciousness, coordination.
• Which movements cause problems, pain? Compensations?

Disorders of active movement:
• Pain, muscle weakness, paralysis, tight/shortened muscles, limited joint mobility, inability to follow instructions

It affects the range of motion:
• Pain + shortening of various tissues + muscle weakness

O – objective part

Passive movement assessment

Aim:
• Determine the end-feel; determine the passive ROM
• Proximal part: stable
• Distal part: moves

End-position can be:
• Bony: elbow joint extension; sudden, forceful, hard stop during movement due to collision of anatomical structures
• Soft: due to soft tissue; elbow joint flexion
• Flexible: shoulder joint adduction; tissue tension, rubbery end-position sensation where tension in soft tissue limits further movement
• Tight: due to ligaments; knee joint extension

Pathological end-feel:
• Tight: e.g.: due to contracture, shorthened tissues
• Empty: lack of end-feel, if the patient stops further movement of the joint before the examiner finds any tissue resistance, always abnormal
• Spastic

O – objective part

Isometric resistance assessment

• To assess the capability of muscle groups to stabilize a joint
• To test the stability of the joint; whether the muscle group can hold the joint – isometric muscle work
• Muscle groups are tested
• Joints are tested in a resting position

Don't let me move you, hold the position

O – objective part

Muscle strength assessment

• ROM; gravity; taking resistance into account
• Scale Grade 0-5 (usually start with Grade 3)
Grade 0: No muscle contraction or movement
Grade 1: Noticeable contraction, but no movement
Grade 2: Movement at the joint with cut off the gravity
Grade 3: Movement only against gravity (full ROM, without tremor, hold for 5 sec.)
Grade 4: Movement against external resistance, but less than normal (weight of the hand)
Grade 5: Normal strength (higher resistance)

O – objective part

Special tests

• confirm the diagnosis
• perform differential diagnosis
• differentiate between the affected structures
• Test for articular dysfunctions
• Test for muscular dysfunctions
• Examination of neurological dysfunction

A - assessment

• Identify strengths/positives (we can build on them) and weaknesses/deficiencies (e.g. disability, that we want to reduce) (good attitude, patient's passive attitude)

• Detailing the problems in order to clearly determine the treatment goal (adapted to the problem)

• Identification of primary problems (major problem for patient and according to PT); secondary problem (problem for patient but no difference according to PT)

• Identify short-term treatment goal (e.g.: reduce symptoms; increase range of motion)

• Set long-term treatment goal (e.g.: improve quality of life, improve function)

P - plan

• Determining treatment goals
• With what frequency?
• For how long?
• Short/long-term treatment plan
• Basic exercises? What techniques will be used? Complementary therapies?
• What else do we suggest? E.g.: assistive device; other specialist
• Prescribe a home program (give homework- complete with drawing)
• The plan can be modified if necessary
• Everything should be recorded in the patient's medical records