SOAP notes

Question 1

S

Answer 1

subjective
update the complaint
How are they today?
How have they been since the last adjustment?

Question 2

accurate description of the patient’s complaint

Answer 2

onset
provoking/palliative
quality
radiation
severity
time/frequency

Question 3

O

Answer 3

objective
what you observe
reports form other doctors
dingins from your exam
radiology reports
inficators of subluxation

Question 4

PART is part of..

Answer 4

Objective findings

Question 5

PART

Answer 5

pain/tenderness
asymmetry/alighment
ROM abnrmality
tissue, tone, texture, temperature abnormality

Question 6

pain/tenderness is identified by

Answer 6

observation
percussion
palapation
provocation

Question 7

pain/tenderness is evaluated by

Answer 7

location
quality
intensity

Question 8

assymetry/alighment

Answer 8

identified on a sectional or segemntal level

observation, static palpation, diagnostic imaging

Question 9

ROM abnormality

Answer 9

changes in active, passive and accessory joint movment can result in increase or decrease of sectional or segmental mobility
identified by: observation, motion palpation, ROM testing

Question 10

tissue, tone, texture, temperature abnormality

Answer 10

chagnes in characteristics of contiguous and associated soft tissues
(skin, fasica, muscle, ligament)
identified through observation, palaption, instrumentation, tests for strength

Question 11

Assessment

Answer 11

impression of current condition
includes diagnosis
no change, improved, worse
what you think
assessment reflects doctor's judgement

Question 12

Plan

Answer 12

care rendered
short term goals
long term goals
discussions with patient
scheduled follow up