Writing SOAP Notes

SOAP Notes

A format/style of documentation in healthcare

Any document can be written in this style

Originally designed for Osteopathic medicine

Designed to achieve a more structured evaluation

Includes a thorough hx & physical exam

Allowed for more accurate Dx

Organized, concise document

Utilizes medical abbreviations

Purpose of SOAP Notes

Liability: legal document

Communication: method to communicate w/

other healthcare professionals and/or your staff

Insurance: third party reimbursement

Progress Report: review report to decide if Tx is

effective

Research: to collect injury data statistics

Education: to improve quality of care

State Requirements

Oregon:

“Athletic trainers are required to accept responsibility

for recording details of the athlete's health status and

include details of the injured athlete's medical history,

including: name; address; legal guardian if a minor;

referral source; all assessments & test results, by date

of service provided; treatment plan and estimated

length for recovery; record of all methods used;

results achieved; any changes in the treatment plan;

record of the date the treatment plan is concluded

and provide a summary; sign and date each entry.”

SOAP Notes

Write it as soon as possible before it fades from

your memory

May have to take notes during the evaluation initially

Notes should organized & chronological

Use subheadings

Underline headings

Notes should include past & present

examinations, tests, Tx, & outcomes

SOAP Notes

Notes must be legible!

Never use “I” refer to your professional title

i.e. ATC, PT

Use quotes whenever possible

Do not use hyphens

Confused w/ minus signs

Use black or blue ink only

Sign all evals and progress notes

What does SOAP stand for?

S = Subjective

O = Objective

A = Assessment

P = Plan

Subjective

Information obtained from Pt

Very important to get a good Hx

The background of the injury will often give you the

answer

Includes:

Hx: pertinent background information

MOI or HPI: how, what, when, where of the injury

C/O: Pt’s sx including description of pain

Meds: current medications being taken (Rx, OTC, sup)

All: any allergies

Subjective Hx:

PSHx, PFHx, Past Tx, social hx, prev injuries, change in activity,

MOI: Any unusual noises/sensations heard/felt

Onset of injury: acute or gradual (chronic)

C/O: complains of (or chief complaints - CC) Pain scale (1-10)

Location, severity, & type of pain Burning, stinging, sharp, dull, deep, nagging, radiating, constant, @

night, in a.m.

Pain worse during or after activity

Limitations from pain What aggravates & alleviates pain

Meds:

All:

Unusual sounds/sensations

Clicking/Locking:

Meniscus/labral injury

Pop:

Ligament injury

Patellar/GH dislocation

Muscle tear

Snapping/Popping:

Tendonitis

Bursitis

Pulling:

Muscle strain

Objective

Physical findings:

Everything you observe, palpate, or test

Typically measurable/repeatable

Includes:

Observation

Inspection

Special Tests

Neurovascular

ROM

MMT

Objective

Begins the moment you first see them

Assess the individual’s state of consciousness & body

language

May indicate pain, disability, fracture, dislocation, or other

conditions

Note their general posture, willingness & ability to

move

When you start your exam:

Check bilaterally & think outside the box!

Don’t get caught up in the specific area

Observation

ALWAYS compare bilaterally

Gait & posture

Obvious deformity

Bleeding

Mental alertness – state of consciousness

Discoloration/Ecchymosis

Swelling

Atrophy/Hypertrophy

Symmetry Scars

Skin

Objective

Palpation:

Deformity

Point tenderness

Temperature

Crepitus

Special Tests: (+/-)

Fx tests

Specific tests for body part

Functional tests

Fracture Tests

Squeeze/Compression

Tap

Ultrasound

Tuning Fork

*Positive Sign: Localized, Shooting Pain

Objective (NV) Neurovascular: (G or P, +/-, WNL/N)

Myotomes - Strength

Dermatomes - Sensory

Skin Temp/Color

Cap refill

Pulse/BP

Reflexes (superficial & deep tendon)

ROM: (in degrees)

AROM/PROM

End feel

MMT/RROM: (out of 5)

Strength tests

Break tests

MMT Scale

0/5: no contraction

1/5: muscle flicker, but no movement

2/5: movement possible, but not against gravity

3/5: movement possible against gravity, but not

against resistance by the examiner

4/5: movement possible against some resistance

by the examiner

Can be subdivided further into 4–/5, 4/5, and 4+/5

5/5: normal strength

Assessment

Your professional opinion of the type of injury/illness

Based off the subjective & objective portions of the

exam

Include:

Anatomical location

Severity

Description

The exact injury/illness may not be known

Exp: Possible 2° L ATFL sprain

Plan

Tx the patient will receive that day

Ice, splint, crutches

Plan for further assessment or reassessment

Patient/Family education: Home instructions

i.e.: Concussion Take Home Instructions

Referral

Short & Long term goals: need to be measurable

Expected functional outcomes

Equipment needs

Plans for discharge/RTP

Plan – Treatment/Therapy

Frequency

Location

Duration

Type

Progression

Example of generic plan:

Pt will be seen TIW x 6 weeks to include TE &

modalities as needed

Plan - Short-term Goals

Goals that will allow Pt to achieve long-term goals

Record specific rehab ex’s

Record any modalities used & exact parameters used

Day to day or weeks

Example:

Increase R shoulder flexion to 145o (from 125o), increase

function so Pt can comb their hair c R hand in 7 days.

List specific stretching & functional exercises

Plan - Long-term Goals

Expected outcomes

Includes:

What is the outcome

What will it take to achieve that outcome

Include measurements and specific interventions for each goal

What conditions must exist for a good outcome

Example:

Return to full strength (5/5 from 4/5), full ROM

(170o from 145o), return to volleyball

List specific strength ex’s, stretches, & sport specific

activities

Progress Note

Written after each eval/rehab session

Can be performed as SOAP note or as a summary

Include response to Tx & type of Tx

Progress made towards short-term goals

Changes in Tx or goals

Important notes:

Seen by physician

Results of diagnostic tests

RTP status

Progress Note - Subjective

Response to treatment & rehab

Decreased/increased pain

Include why: from rehab, standing all day, etc

Overall psychological profile (i.e. bored)

Reassessing subjective information from

previous notes

Change in function

Change in pain (location, type)

Patient compliance issues c ex’s

Progress Note - Objective

Tx provided

Reassess & compare measures that may have

changed

Note changes in ROM, strength, functional ability

Indicate any changes or special notes for rehab

Change in modality parameters

Assistance needed/not needed during exercises

Added/decreased weight/reps/sets/frequency

Added or changed exercises

HIPS/HOPS

History

Observation/Inspection

Palpation

Special Tests