SOAP notes Flashcards
1
Q
PT sig
A
- always for students
- in co, not for PTA
- APTA says always yes to help maintain team dynamic and collaboration (insurance)
2
Q
S O A P
A
Subjective
Objective
Assessment
Plan
3
Q
Subjective
A
- relevant info that pt, SO, or caregiver communicates
- pt’s statements or complaints
- pain scale, doing HEP
4
Q
Objective
A
- info the PTA observes during treatment
- info that can be measured and confirmed by another provider
- description of PT interventions used during treatment session
5
Q
Assessment
A
- pt’s response to treatment
- progress, goals, effective intervention?
- bring summary of subjective and objective
- all statements must be supported by S O
6
Q
PTA assessment
A
- according to APTA, PTA can assess how the pt tolerated treatment and their progress towards goals
- PTAs cannot evaluate or reevaluate a pt
- PTAs should only summarize that data form S O sections
- reassessment data is collected by the PTA on regular basis to be interpreted by the PT; this data is documented in the objective section of the SOAP note
7
Q
Plan
A
- what will be done in next session
- equipment to be ordered
- number of treatment sessions before discharge
- plan to follow up with PT
8
Q
POC
A
- PTAs cannot evaluate, develop, or modify
- PTAs may progress a pt within POC
- PTAs cannot modify the treatment plan established by the PT but may need to modify a specific treatment
9
Q
Dos and Donts
A
DO - write if the pt was going to read - draw one line across and initial (mistake) DONT - use white out, scratch out mistake - use first person language
