SOAP Notes

Question 1

Role delineation in daily notes

Answer 1

OTR and COTA can write notes
NOT Aides
OTR usually reviews and cosigns

Question 2

Who require cosignature?

Answer 2

Depends on state licensure law
Does Alabama??
Facility requirement
Payor requirement

May be required every time
Once a month on a supervisor visit
Weekly

Question 3

Subjective

Answer 3

Patient complaints, comments
Family comments
Quotes or not
Should be relevant
May be blank

Question 4

Objective

Answer 4

Facts
What happened in therapy and the outcomes
Can start with a why or where the client was seen statement
Can be arranged
- Chronologically
- Categorically

Question 5

Examples of subjective

Answer 5

Pt reports she did not sleep well and it might effect her therapy performance
Pt reports she bought a new silk gown yesterday at the mall

Question 6

Example of objective

Answer 6

Pt was seen in her room for morning dressing group. PT doffed her night gown and was able to ambulate to the closet to choose clothes for the day. She was unable to reach items on the top shelve due to decreased shoulder rom. Pt was instructed to use a reacher and was able to retrieve items using it. Pt was then able to don all clothes except for bra, she required max assist to hook bra. Pt then performed AROM and AAROM exercise x 15 reps of abduction, flexion, internal and external rotation with both shoulders. Pt also performed a functional task aimed at increasing ue endurance for 8 minutes. Following intervention, she was able to get edges of bra within 2 inches of clasping

Question 7

Assessment

Answer 7

Explains what the O means
Think about the problem list
- Then match the O to it

Question 8

Example of assessment

Answer 8

Pt is near independent in her ability to perform activities with her UE when using adaptive equipment, however Pt. has a strong desire to regain function without the use of adaptive equipment. She has improved by approximately 50% in 3 weeks. With continued therapy, it is reasonable that client will be able to reach normal function.

Question 9

Plan

Answer 9

Should contain freq and duration and what you are planning next

Question 10

Example of plan

Answer 10

Continue therapy 3 x week for 3 weeks to increase UE AROM and thereby increase function. Begin to wean patient off of adaptive equipment

Question 11

Things to use for daily notes

Answer 11

Attendance logs
- Not enough alone
Flow sheets
- Don’t get limited by space
Photographic and video documentation
- Wound is 4 cm in width, it is pink and granular with no exudate or sign of infection
Medicare Progress note
- Every ten visits or 30 days