SOAP Flashcards
Type of note that is
• Comprehensive
• History taking, interviews physical assessment
Initial Note
Type of note that is
• status, intervention given, and response of the
patient
Progress Note
Type of note that is • The patient can be discharged if the patient is well • How many sessions • Patient’s outcome • Goal achieved • Moving of facility/hospital
Discharge Note
• Examination
Subjective (S)
Objective (O)
• Evaluation
Assessment (A)
• Diagnosis
Assessment (A)
• Prognosis
Assessment (A)
• Intervention
Plan of Care (P)Patient /Client mgmt Process and Documentation Formats
Guidelines in Writing a Medical Record
• Accuracy - straight-forward
• Brevity - Brief and Concise
• Clarity - Clear and Specific
• Punctuation - to make the statement short and not
to be redundant
• Hyphen (-), semicolon (;), and colon (:)
• Correcting Errors - sign the correction, date of the
correction, licensed number.
• Signing your notes (authentication)
• Referring to yourself
• Blank or empty lines
• Writing orders in a chart as in the case of v.o.
(verbal order) - if through telephone, it must be list
down and signature should be there.
J. Goals
• Subjective (S)
- Information gathered from the patient or the
caregiver.
• Subjective (S)
A. General Information
• Subjective (S)
B. History of Present Illness - event/processes
that resulted to the present illness
• Subjective (S)
C. Family Medical History recurrent
• Subjective (S)
D. Personal Social History - hobbies,
recreational jobs/ smoker
• Subjective (S)
E. Environmental Assessment - home and work;
to modify the environment and to make the
patient adapt to the environment.
• Subjective (S)
F. Home situation - Social structure in relation to
his/her family; example: bread winner, social
support, and living with whom
• Subjective (S)
G. Laboratory and/or Ancillary procedures -
insert the necessary information. (MRI, CTscan,
X-ray). MRI is used for Basis
• Subjective (S)
H. Medications taken - implication of the
medicine; example: during treatment, patient
uses muscle relaxants.
• Subjective (S)
I. chief complaints
• Subjective (S)
• Subjective (S) Guidelines
• Guidelines
• Use of the term patient - should be avoided to
save time.
• Verbs - indicates that the information is from the
patient. (ex: states, illustrates)
• Quoting the patient verbation
• Quoting the patient verbation
- To illustrate confusion and memory loss
- To illustrate denial
- To describe pain
• Documentation of the results of the PT’s tests and
evaluation procedures
Objective (O)
• Objective and measurable - non-bias and
accurate
Objective (O)
Assessment and Evaluation (A)
Objective (O)
• The Therapist looks at the severity of the :
patient’s functional deficits and impairments,
the patient goals,
living environment,
predicts a level of improvement in function,
the amount of time needed to reach the level.
• Prognosis
