SOAP & SMART Flashcards
What is the job of a physiotherapist?
Develop, maintain and restore people’s maximum movement and functional ability.
Help people maximize their quality of life, looking at physical, psychological , emotional and social wellbeing.
What is assessment based on?
International classification of functioning, disability and health (ICF).
- Health condition
- Body functions and structure
- Activity
- Participation
- Environmental factors
- Personal factors
When should an assessment be done?
- At first contact following referral (baseline for progression)
- At the beginning of every visit / contact (monitor change between each session / first session)
- After each intervention (effect of intervention?)
- At the end of the rehabilitation program
Is an assessment always relevant?
No, assessment is not always representative of patient’s current health status due to patient being unwell, lack of privacy, patient not being dressed appropriately.
What is the content of record keeping and why is it a crucial part of treatment?
Patient’s initial level of activity/ performace/ effects of treatment and final outcome.
- allows to track the progress of the patient
- allows other clinicians to provide treatment
- they are legal documents.
What do physio’s note need to contain and why?
Legal documents, need to contain date, time, full name and signature of physio for each entry.
May be used in court, safety for therapist.
Proof that client has given informed consent.
What must a patients file contain?
- Patient personal data
- Medical diagnosis
- Previous condition
- Pathology requiring physiotherapy
- Medical examination report
- Physiotherapy initial and final assessment
- Function, activity, participation
- Results
- Advices
SOAP
Subjective
Objective
Analysis/assessment
Plan
What data is gathered during subjective assessment?
a. the patient’s perceptions of his/her needs
b. the patient’s expectations of physiotherapy intervention
c. the patient’s demographic details
d. presenting condition/problems
e. past medical history
f. current medication/treatment
g. contra-indications/precautions/allergies
h. social and family history/lifestyle (effects of impaired activity and participation, ICF)
i. relevant investigations
Subjective Assessment of Pain - SIN
- Severity – how intense is the pain?
- Irritability – how much / little does it take to provoke it, and once it is there, how long does it take to settle down?
- Nature – is it likely to stem from bone, muscle, tendon, ligament, nerve, fasciae, internal organs etc?
Objective Assessment
physical examination carried out to
obtain measurable data with which to analyze the patient’s
physiotherapeutic needs.
What is important to remember regarding objective assessment?
Findings of the clinical assessment are explained to the patient.
If any of the required information is missing or unavailable, reasons for this are documented.
Analysis
In order to formulate a treatment plan.
- evidence of a clinical reasoning process.
- written evidence of identified needs/ problems (ICF)
Able to answer the question: “Do the features fit?”
- Objective measures are identified, recorded and evaluated.
- Physiotherapy diagnosis with relevant signs and symptoms is recorded.
- Patient expectations should be elicited and documented.
Physiotherapy Diagnosis
Refers to the presenting physiotherapy problem. Expressed in terms of how a condition compromises the functioning of a patient. Can be in conjunction with a medical diagnosis.
Plan
Evidence based practice.
- patient is fully involved in any decision-making process during treatment planning.
- consider the patient’s and/or caregiver’s needs within their social context.
- treatment plan clearly documents the chosen (and agreed!)
interventions.
- date, version, source of clinical guidelines or local protocols are recorded if used.
