SOAP Notes

Question 1

What are SOAP notes?

Answer 1

This is a common method of documentation used in the health care system.

An acronym for Subjective, Objective, Assessment, and Plan.

Question 2

S (Subjective)

Answer 2

• Information recieved or stated by patient/family or interdisciplinary team (IDT)
• Relevant to pt’s condition
• Use verbs such as “states, denies, reports, c/o”
  - Avoid using negative verbs (complain)
• Incorporated in every note

Question 3

Subjective Components

Answer 3

• Consent to tx
• Information about pt’s hx
• Symptoms or complaints that caused the patient to seek medical attention
• Factors that produced the symptoms
• Functional and lifestyle needs
• Goals and expectations about medical care

Note: Use quotations on important statements from pt.
- Pt stated, “My hip hurting” when completing LE dressing.

Question 4

Example of Subjective Notes

Answer 4

Pt reports having lower back pain aggravation while standing and reaching overhead for more than 15 minutes (working on cars up on rack). PMT of lower back pain for 5 years. NPRS at 1/10 at rest and 7/10 with aggravating factors.

Question 5

O (Objective)

Answer 5

• Impairments
• Observations
• Measurements performed
• Information from:
  - Medical records (diagnostic)
  - Testing (therapist)
• Incorporated in every note

Question 6

Objective Components

Answer 6

• The results of the measurements and tests
• Description of pt’s function
• Detailed description of interventions provided
  - Such as ICF, TENS, laser, ultrasound, etc.
• OTA/PTA’s objective observations of the pt
• How pt tolerated the treatment session
• A record of the number of treatment sessions provided (might be included in ‘P’)

Question 7

Example of Objective Notes

Answer 7

Pt observed having slouched posture, head forward, knees hyperextended. Full AROM thoracolumbar region with minimal pain at end range lumbar extension. Decreased in strength in bilateral hip ext/flex (4/5). Sensations are NWL.

Question 8

A (Assessment)

Answer 8

• Only the therapist (PT or OT) would write in this section
• A summary of ‘S’ and ‘O’
• Problems, diagnosis, and prognosis
• Goals (STG & LTG) and expected functional outcomes
• Incorporate in notes if appropriate (therapist’s judgment)

Question 9

P (Plan)

Answer 9

Future considerations:

• Frequency and type of treatment
• Plans for progression of treatment or discharge
• Equipment to be used
• Referral to other health care services

Question 10

Plan Component

Answer 10

• What is the plan after the treatment session?
• Communicate with PT or OT for re-treatment session
• Express any concerns from pt to team members
• Any changes to goals?
• Continue with treatment planned by PT/OT
• When is the next appointment?

Question 11

Example of Plan Notes

Answer 11

Proceed with the TENS application and teach pt mid, lower thoracic, and the lumbar region stretching techniques. No referral advised. Appointment set for February 10, 2020 12:00.