Sections of a SOAP Note

Question 1

Pt reports chief complaint is pain and stiffness

Answer 1

Subjective

Question 2

Pt lives with wife and 2 small children

Answer 2

Subjective

Question 3

L knee AROM 10-120 degrees

Answer 3

Objective

Question 4

Pt amb with FWW x 100’ with minA x 1

Answer 4

Objective

Question 5

Pt transfers from sit <>stand without assistance today, demonstrating pt has met goal.

Answer 5

Assessment

Question 6

Pt receives R forearm PROM for supination and pronation in sitting 2 x 10 ea

Answer 6

Objective

Question 7

AROM (R) elbow: 0 - 125 degrees

Answer 7

Objective

Question 8

Pt’s gait distance improved from 25’ yesterday to 120’ today

Answer 8

Assessment

Question 9

Add quadriceps setting, terminal knee extensions, and straight leg raises during next session.

Answer 9

Plan

Question 10

Strength (L) LE: Knee ext 4/5, knee flex 5/5, ankle DF 3/5, ankle PF 2-/5

Answer 10

Objective

Question 11

Pt c/o pain in the R hip

Answer 11

Subjective

Question 12

Pt is oriented x 3

Answer 12

Objective or Subjective

Question 13

Transfers: (I) with sliding board

Answer 13

Objective

Question 14

Wound now consists of 75% healthy granulation tissue as compared to 10% last month

Answer 14

Assessment

Question 15

3 MHz US (50% duty cycle, intensity 1.0 W/cm2) to dorsal aspect of left foot with US gel

Answer 15

Objective

Question 16

w/c mobility: PT propels w/c on an outside sidewalk and up and down ramps with VCs for trunk positioning while on ramps

Answer 16

Objective

Question 17

Pt c/o finger swelling and pain 7/10 since last tx session.

Answer 17

Subjective

Question 18

Reports being unable to perform any ROM ex. d/t pain.

Answer 18

Subjective

Question 19

Pt. reports difficulty eating and shaving d/t swelling and stiffness in the digits.

Answer 19

Subjective

Question 20

Pt. ambulates 10’ x 2 with minA x 1 using standard walker NWB (R) LE with VCs for walker placement 100% of the time

Answer 20

Objective

Question 21

(R) LE Girth: knee joint line 34cm, 2” above 38 cm, 4” above 42 cm, 4” below 35.5 cm

Answer 21

Objective

Question 22

Vital signs before tx: BP 125/85mmHg, RR 15 breaths/min, HR 77bpm

Answer 22

Objective

Question 23

Pt ambulates (I) with axillary crutches WBAT x 100’

Answer 23

Objective

Question 24

Pt. indicates d/c plans are to return home

Answer 24

Subjective

Question 25

Pt's wife reports pt. has been unable to get out of bed I x 2 weeks

Answer 25

Subjective

Question 26

A/PROM DF have increased 5 degrees since initial visit.

Answer 26

Assessment

Question 27

During gait he has increased his stance time on the involved extremity since previous tx session.

Answer 27

Assessment

Question 28

Ability to amb stairs has improved. At the previous visit she could only perform 3 steps and is now able to do 1 flight

Answer 28

Assessment

Question 29

Increase pt's (I) on stairs

Answer 29

Plan

Question 30

Continue working toward (I) with transfers on sliding board

Answer 30

Plan

Question 31

Cont. PT BID for NMR, strengthening, mobility training, pre-gait activities, endurance activities, balance training, and education related to positioning and self-care

Answer 31

Plan

Question 32

Pt requires Sit <> stand maxA, mod stand-pivot from therapy mat to/from w/c modA, modA and constant v/c's for w/c set-up d/t impulsivity and safety issues

Answer 32

Assessment

Question 33

Will report pt's decline in status to the PT.

Answer 33

Plan

Question 34

Will cont. to work with pt. on bed mobility, transfers, and strengthening exercises

Answer 34

Plan

Question 35

Demonstrates abnormal heel-to gait pattern (R) LE, has tendency to keep (R) LE extended when walking

Answer 35

Assessment

Question 36

Pt to return to clinic 02/25/21, will focus on strengthening and proprioceptive exercises for R knee

Answer 36

Plan

Question 37

Pt. has made improvements as demonstrated by meeting STGs 2 & 3

Answer 37

Assessment