SOAP Notes

Question 1

S

Answer 1

Subjective

Question 2

O

Answer 2

Objective

Question 3

A

Answer 3

Analysis or Assesment

Question 4

P

Answer 4

Problem List and Plan

Question 5

Subjective

Answer 5

Info received from the patient.
-Opinions, goals, feelings and perceptions of their own health

Question 6

Objective

Answer 6

Observable information that the clinician gathers during assessment and treatment session
-SEEN, MEASURED, AND TESTED
-Treatment, Clinic Tests and Measurments

Question 7

Analysis

Answer 7

Summary statement based on the subjective and objective findings.
-Progression, Regression, No change
-A candidate for Kin or needs a referral?

Question 8

5 Components of Analysis

Answer 8

1) Client Profile/Summary
-Name, DoB, Sexm Pronouns and Sig Presentation

2)Present condition/diagnosis
-Current diagnosis, differential diagnosis.

3)Any Risks
-Acuity/Chronicity/Stability and any risks
-Primary Concerns, Precutions, Contras, assesment of patients primary concern/goals

4)Prognosis and Rational
-What os the possible diagnosis and why
-Potential future ramifications
-Are they able to achieve goals

5)Potential for Kin or Referall to other services
-R.kin offer
-Refer other

Question 9

Problem List

Answer 9

Problems addressed by Rkin or requires consult
-Actual problems or at risk for

ie; low cardio due to sed lifestyle

Question 10

Short Term Goals

Answer 10

Address function, impairments or education

Question 11

Longterm Goals

Answer 11

Resolving problem list
Meaningful return to activity

Question 12

Plan

Answer 12

A concise statement of overall intervention plan and follow up proposal for next session
-What is the treatment
-How do achieve goals
-NExt appointment plans