Filling Out the OPP SOAP Note

Question 1

Questions to include in the history

Answer 1

1. dental/ orthodontia history- including retainers, braces, fillings; wisdom teeth/ other extraction; oral surgeries; complications of any of the above
2. Birth history- vaginal vs C-section, complications
3. Sports played, current and in the past. Sports-related inuries

Question 2

Where are structural findings documented ? (T4FRSR)

Answer 2

the physical exam section

Evaluate the entire individual, not just the area of injury

Question 3

minimum area to assess

Answer 3

one joint above, one joint below the area of injury

Question 4

Assessment section

Answer 4

list allopathic dx first, then the somatic dysfunction diagnosis

example: somatic dysfunction of the head, cervical, thoracic, lumbar, sacrum, pelvis, LE regions. List every region where SD i found, even if you did not treat it with OMM.

Question 5

Plan section

Answer 5

document advice and when pt should follow up

Question 6

OMM is a procedure so…

Answer 6

a procedure note should be written once it’s been performed and neds to be clearly and separately identifiable within the SOAP note.

Verbal consent must be obtained and documented.

Clearly document which regions were treated and what techniques were used on each corresponding region.