SOAP

subjective

patient statements

PMH (past medical history)
CC chief complaint

Pain

How pt felt after last tx

Objective

measure facts and information

vital signs

examination findings/measurement

rom, strength, girth measurements

laboratory data

what patient did during treatment

treatment/interventions

assessment

clinical reasoning

clinicians assessment of how the patient did during treatment

possible interactions

changes in status

pt response to tx

patient goals

diagnosis

problems

plan

plan of action

what will pt/pta do

list of interventions to be used next appt.

further testing

Flow sheet

pta/pt aide can mark on this to track exercises