Soap Notes

General Announcements

No feedback was given on the first SOAP note assignment prior to submission, as it was assumed changes would be made based on peer feedback. Full credit was given for the first part.
The instructors will read through the submissions and provide answers at the end of the session.
Dr. Fairfield will review answers to last week's activity, followed by another SOAP note activity.
The assignment for module four will be discussed at the end of class.

Tyler: Injured on the Job

Tyler is participating in a work conditioning program five days a week.
The SOAP note that matches Tyler is a functional capacity evaluation interim report.
The subjective report indicates shoulder soreness and motivation about returning to work.
Specific testing metrics are included, as the employer is aware of the injury.

Zora: Elementary School Teacher with Wrist Injury

Zora is a 40-year-old elementary school teacher with private insurance or private pay, seeking outpatient hand therapy for a wrist injury.
Subjective comments include difficulty with typing, opening jars, and gripping markers.
Zora denies pain or swelling but is motivated to resume work by the end of school break.
The plan includes continuing therapy twice a week, focusing on progressive strengthening and grip tolerance, and educating on joint protection.
JT (joint protection) is a common abbreviation in hand therapy.
The plan includes reassessing grip strength and range of motion and coordinating with the employer regarding a return-to-work timeline.
Objective measurements of grip and degree are included in the objective section.

Jeff: Executive Functioning Deficits from TBI

The SOAP note matches Jeff based on its focus on executive functioning from TBI (traumatic brain injury).
The assessment indicates deficits consistent with moderate TBI.
The session is cognitive-based, measuring errors and task performance.
The objective section lists specific metrics from Trail Making Test B, a common executive functioning screen.
The plan includes memory compensation devices typically used in TBI.

Smith: Cerebral Palsy (CP) Receiving Clinic-Based OT

Smith is receiving clinic-based OT (occupational therapy), not related to the school system.
Activities include play-based interventions, ADLs (activities of daily living), and various tasks not typically seen in school-based practice.
Specific ADLs like donning a shirt and socks suggest home-based or clinic-based therapy.
Abbreviations: HOH (hand over hand assistance), VC (verbal cues), AE (adaptive equipment), CG (caregiver modeling).
The Petty Cat is an assessment to be delivered as part of the reassessment plan and updating long-term goals (LTGs).
HOH can also mean "hard of hearing," so context is important.

Anisha: Private School Student with an IEP

Anisha is a private school student with an IEP (Individualized Education Program) and is seen for fine motor impairment in a public setting.
The format differs from a standard SOAP note, with fillable form fields formatted for IEP documentation.
The note addresses IEP goals, present level of performance, and supports/accommodations.
Progress towards IEP goals is specifically addressed with various timelines.
SOAP format is generally not used in IEP-related services.

Paul: Total Knee Replacement at a SNF

Paul has a total knee replacement and is at a Skilled Nursing Facility (SNF), receiving OT focused on ADLs.
He is likely supported by Medicare.
Subjective: Complains of mild left knee pain (3/10) and feelings of imbalance when getting out of bed (OOB) or reaching for items; wants to get back to doing things.
Objective: Completing bed mobility, edge of bed (EOB) with standby assist; performs sit-to-stand transfer from bed to chair using front-wheeled walker with one verbal cue; completes lower body dressing trial with minute assist and verbal cues; standing tolerance at bathroom sink for 5-6 minutes with a seated rest break.
Gait assessed on a level surface for 40 feet using a front wheel walker and standby assistance; antalgic gait noted with a slight left lean and decreased weight bearing on the left lower extremity (LLE).
Able to retrieve grooming items from standing cabinet shelf with contact guard assistance (CGA) for balance support.
Assessment: Gradual increase in functional mobility (FXNL MOB) and safety awareness during ADLs; status post (SP) left total knee replacement.
Abbreviations common in medical environments.
Plan: Continue OT two times a week for ADL and assistive equipment use; TUG (Timed Up and Go), BERG (Berg Balance Scale) will be reassessed; develop HEP (Home Exercise Program) for lower body dressing.

Dahr: Army Sergeant with Spinal Cord Injury

Dahr is a 45-year-old Army sergeant with a spinal cord injury (SCI) that occurred on active duty with 100% service connection, focusing on self-care and community mobility.
The individual is referred to as a veteran.
Subjective section includes quotes and statements addressing specific aspects of dressing and performance.
Assessment: Veteran continues to gain self-care independence following SCI.
Setting-specific abbreviations enhance documentation efficiency.

Regina: Home Health after Total Hip Replacement

Regina is receiving OT through home health after a left total hip replacement (THR).
Posterior approach indicated hip precautions.
Abbreviations: DME (durable medical equipment), FWW (front wheel walker), RTS (raised toilet seat), BSC (bedside commode).
The instructors clarified that abbreviated terms may differ across practice settings.

Key Documentation Points

Subjective statements are what the patient reports; objective statements are what the therapist observes.
Information not observed goes in the subjective section.
Documentation varies across settings due to populations served and funding sources.
Notes are examined initially, then audited, with education and support provided for missing information.
Documentation serves multiple purposes: billing, legal protection, and transfer of care.
Flexibility and understanding the audience are important.
Increase can be abbreviated as INC or DEC.
EMR (Electronic Medical Record) systems may have shortcuts and transportable text for documentation.

SOAP Note Activity: General Anxiety Disorder

Client reports sleeping only 3-5 hours per night with daytime fatigue: Subjective (S).
Demonstrated improved engagement with use of visual cueing during session: Objective (O).
Client will utilize a visual checklist to complete morning routine tasks daily: Plan (P).
RTI-E scores indicate significant difficulty with complex IADLs such as meal prep and money management: Objective (O) - Standardized assessment data.
Client expresses "I just feel like I'm stuck in my head all day": Subjective (S).
Client scored 3/10 for performance and 2/10 for satisfaction on the COPM: Objective (O) - Numerical score from a standardized assessment.
The assessment section is the therapist's interpretation of the session.
OT observed client needed verbal prompting to initiate tasks during session: Objective (O).
Client has not engaged in photography or art, previously enjoyed leisure interests: Subjective (S).
Client will prepare meals three times a week using a simple three-step meal planning template: Plan (P).
Client appeared guarded but cooperative throughout session: Objective (O).
OT to address past initiation strategies to support independent meal preparation and planning management: Could be Assessment (A) or Plan (P).
Client lives alone and avoids phone calls and social contact: Subjective (S).
Client identified three main goals: establish morning routine, prepare meals, and re-engage in photography: Subjective (S).
OT recommends 2x/week outpatient sessions for 6 weeks to address performance deficits in IADLs: Plan (P).
Client denies substance use and reports medication compliance: Subjective (S).
OT impression: Client demonstrates insight into his challenges and motivation for change indicating good rehab potential: Assessment (A).
The assessment is where the therapist adds clinical value based on performance.
SOAP notes are more common than SBAR.

Module 4 Assignment: Auditing a Daily Note for Leo

Students will audit a daily note for Leo by annotating a PDF with comments, providing feedback on what could be improved.
Download the non-fillable PDF and add comments throughout.
After me and Dr. Fairfield provide feedback and add comments to your comments.
Week six, rewrite the not using feedback and our feedback.
Provide your comments of what you think could be better. This is just adding comments of where, what that note should look like. You guys should be reading in your book about notes and what should be appropriate in your notes, and then what the things we've learned about in class thus far. So there should be no editing of the within the note itself. It is just adding comments.
The annotated PDF should be submitted with a specific file name including the student's name.
A template with comments is provided to guide students on what should be included in each section.
In week five you take that feedback and rewrite the note.
The second part involves students rewriting the note based on the feedback received.
The assessment you make a interpretation of her performance.
There is a peer feedback component to this assignment.
If encountering difficulties with annotations, students should seek assistance from IT.
The is due on the May 30th (Friday).