Lecture 1 SOAP notes

Question 1

Purpose of Documentation

Answer 1

Protects the rights of patient and provider (these are legal docs)
-Method of communication between health professionals
-Insurance coverage/reimbursement decisions may be made based
on notes
-Helps achieve consistent care between providers
-Organizes care for provider and patient

Question 2

What does SOAP stand for

Answer 2

• Subjective
• Objective
• Assessment
• Plan

Question 3

Subjective is what the patient tells you… like

Answer 3

• Their history/lifestyle/occupation
• Emotions/attitude/stress
• Their c/c, pain/how it affects them
• Their response to treatment
• Anything relevant that comes out of their mouth.

Question 4

Objective is what health care professionals measure/observe… like

Answer 4

-Was part of an existing medical file
-Result of an objective measurement/observation (ie ROM of knee)
-Is part of treatment given/ability to perform treatment (level of
competency or strength doing activity)

Question 5

Assessment contains 4 categories

Answer 5

• Problem list
• Long term goals
• Short term goals
• Summary

Question 6

problem list includes…

Answer 6

The problem list summarizes the problems as written in both the
subjective and objective portions of the notes
-Providers diagnosis/index of suspicion

Question 7

Long term goals includes

Answer 7

States the final product of treatment/where the patient and
provider want the patient to be
-Set after a problem list is compiled

Question 8

Short term goals include

Answer 8

Outlines incremental and appropriate steps taken to achieve the
long term goals agreed upon
-Set after a long term goals are determined

Question 9

Summary includes

Answer 9

Opportunity for provider to draw correlations between S, O, A,
portions of notes that wouldn’t necessarily be obvious to other
providers.
-May also include inconsistencies between findings and patient
complaints, or justifications for goals set.

Question 10

Plan details the patients treatment includes

Answer 10

Plan includes treatment regime for patient, and MUST include:
-Frequency per day/week patient is seen
-Treatments clinically & exercise that patient receives
-If discharged, where patient is going and how many times
they were seen

Question 11

Plan may also include additional details like

Answer 11

Locations of treatments (pool, turf, home, clinics)

• Plans for future assessments/reassessments
• Equipment ordered/needed
• Referral to other services

Question 12

When do we need to chart?

Answer 12

It is very important to chart if:

• Assessing or providing treatment to a patient/athlete
• Any communication with your patient/athlete regarding their injury
  (ie. they call to ask advice)
• Any communication with other health care professionals
• Any test results or addition info is received.

Question 13

What else do we need to include within SOAP notes?

Answer 13

• Health history form
• Consent to treatment
• Permission to release of medical information
• Copy of referrals if applicable
• Copies of anything given to patient/athlete (ie. pictures of exercises)

Question 14

Informed consent has 3 primary purposes

Answer 14

-1. Protects the individuals right to “security of the person” (Canadian Charter of
Rights and Freedoms)
-2. Enhances communication and trust between caregiver and care
recipient
-3. Risk management measure to avoid potential litigation

Question 15

Informed consent has 7 criteria for validity

Answer 15

7 Criteria:

• Informed
• Voluntary
• Competence
• In best interest of patient
• Mental Capacity
  
  • Specific and not misrepresented
• Opportunity to ask questions