report writing

Question 1

SOAP- what goes under S

Answer 1

subjective:

• includes age
• level of care
• medical hx
• pt. complaint
• clinical bedside eval findings
• MD concerns
• what they’re being referred for

Question 2

SOAP- what goes under O

Answer 2

objective:

• includes what was done
• include views (lateral? A-P?)
• textures tried

Question 3

SOAP- what goes under A

Answer 3

assessment:

• include phases of swallowing
• include deficits
• discuss cause/effect
• strategies/positions that worked

Question 4

SOAP- what goes under P

Answer 4

plan:

• diet recommendations (both solids & liquids)
• swallow therapy recommendations
• positions
• strategies
• exercises
• other specialty recommendations (GI, UGI, voice evaluation, etc)
• goals