SOAP Note Flashcards
S - Subjective Information
History of Current Condition
Past Medical History
Social History
Patients Goals
History of Current Condition
Age, Gender, Chief Complaint, When has pain vs. when doesn’t, Verbal pain scale of current, at worst and at best
Past Medical History
Any prescriptions currently taking, or pain killers
And History if any known conditions
Social History
Career, Marital Status, Children, Any current difficulties in this area of life
Patients Goals
Expectations for what PT will be and what it can do for patient to get to where they want to be
O - Objective Information
These are the results of test and measures you perform
This also includes the patient’s tolerance of the activities done during the current session
Objective Information would include…
Systems Review, Anthropometric Characteristics, Arousal attention and cognition, Circulation, Cranial and peripheral nerve integrity, Gait locomotion and balance, Joint integrity and mobility, Muscle performance, Pain, Posture, ROM
Systems Review
Assuring that your patient should be in PT and not somewhere else
Screening for problems
Look at Integumentary, Cardio, Pulmonary, Musculoskeletal, Neuromuscular, and communication/cognition Maybe gastro and uro too
Anthropometric Characteristics
Height and Weight
Circulation
Pulses detected, color, temperature
A - Assessment
This section contains your evaluative findings
Includes problem list, diagnosis, and prognosis
Problem List
Impairments… what can they do or not do
Participation
Can they work? Do role of mother? Or whatever it is that they need to do?
Diagnosis
Look at the guide for how to write a specific diagnosis
Don’t necessarily have to say for how long or how often will be in PT
Mention how healthy you think you patient will get
Goals
Short and Long term (may depend on your specialty)
