soap

Question 0

objective

Answer 0

# of skilled treatments provided, reasons for missed sessions 
type of treatment given
recordable and measurable progress
the WHAT? did you do to make this happen
observable and measurable treatments

Question 1

subjective

Answer 1

symptoms of patients
complaints
statement or question from patient
patients reaction to therapy

Question 2

assesment

Answer 2

• Professional opinion
• response to treatment
• document changes *problem
  * potential
  * progress
• benefits of treatment
• the WHY? only you can get them to the next level

Question 3

Plan

Answer 3

services to be provided 
frequency and duration
recommendations 
treatment plan
D/C