SOAP Study Guide Vocabulary Flashcards

Vocabulary flashcards covering clinical documentation guidelines, note types, SOAP format components, and ABCD goal design based on the SOAP Study Guide.

SPTA

Professional designation standing for Student Physical Therapist Assistant.

V.O.

Abbreviation standing for Verbal Order.

T.O.

Abbreviation standing for Telephone Order.

Documentation Error Correction

The procedure of crossing a single line through a mistake and writing the date and initials above it, without using white-out, erasures, or deletions.

Verbal Physician Order Documentation

Documentation entered by the receiving therapist containing the date, time, order details, physician's name, and therapist signature.

Accuracy in Documentation

The standard requiring that data is never recorded falsely, guessed, made up, or exaggerated.

Brevity in Documentation

Expressing information concisely using short, to-the-point sentences while avoiding long-winded statements.

Clarity in Documentation

Writing in a manner where the meaning is immediately clear to the reader.

Legibility in Documentation

Writing that is easy for the reader to read and understand.

Skilled Care

Reimbursement-qualifying care that requires the knowledge, judgment, and skilled rehabilitation techniques of a licensed PT or PTA.

Reasonable and Necessary Services

Services supported by clear evidence that they are appropriate for the condition, based on factors of amount, frequency, and duration.

HIPAA

Federal regulations that prohibit the release of patient health information without authorization and mandate national security standards for electronic healthcare information.

Department of Health and Human Services

The federal department responsible for establishing HIPAA security standards.

Initial Evaluation Note

A note performed exclusively by the PT (not a PTA) that generates the patient's diagnosis, prognosis, and plan of care.

Daily Note

A note written by a PT or PTA after every individual treatment session.

Progress / Re-evaluation Note

A note written periodically by a PT or PTA that allows for changes to the prognosis and plan of care as needed.

Discharge Note

A note used to document a patient's discharge from therapy, which PTAs are permitted to write in Illinois.

SOAP

An acronym representing the four sections of patient documentation: Subjective, Objective, Assessment, and Plan.

Subjective Section (SOAP)

The documentation section containing relevant information reported by the patient or family member, including verbatim quotes, complaints, goals, demographic info, environment, medical history, and HEP compliance.

Objective Section (SOAP)

The documentation section containing measurable or observable information, such as test measurements (e.g., MMT, goniometry), numbers, sets, repetitions, equipment used, and treatment given.

Assessment Section (SOAP)

The documentation section containing diagnosis, clinical reasoning to interpret findings, status/progress updates, and goal progress.

Plan Section (SOAP)

The documentation section detailing exercise progression, HEP, equipment/modalities, protocol progression, and changes to the plan of care.

POC

Abbreviation standing for Plan of Care.

ABCD Goal Format

A framework used to describe the structure of a goal, standing for Audience, Behavior, Condition, and Degree.

Audience (ABCD Goal)

The component of an ABCD goal representing the patient or family member.

Behavior (ABCD Goal)

The functional component of an ABCD goal consisting of an action verb followed by the object of the behavior.

Condition (ABCD Goal)

The component of an ABCD goal describing circumstances under which the behavior occurs, including position, equipment, or provided assistance.

Degree (ABCD Goal)

The component of an ABCD goal describing the measurable amount, such as the number of repetitions or times per day.