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.
What information is clearly documented in the treatment plan?
a. time schedule
b. goals (SMART!)
c. outcome measures
d. the identification of those who will deliver the treatment plan
e. relevant risk assessments
f. delegation of activities to assistants or caregivers
Why does the treatment plan need to be constantly evaluated?
to ensure that it is effective and relevant to the patient’s changing circumstances and health status.
at each treatment session there is a review of:
• the treatment plan
• subjective measures
• objective measures
• relevant investigation results
SMART Goals
Safe and effective, quick and efficient return to optimal level of activity.
- Specific
- Measurable
- Action oriented
- Realistic
- Timed
Needs to be direct relationship between the problem and the goals of the treatment.
Why use SMART goals?
- Helps to break-down long term goals into more achievable sub-goals: Progression, Success
- Demonstrate progress against baseline measure: Confidence boost
- Structure a PT program
Specific
who , what, where and why? What will the patient or caregivers do?
Customize the goal to the patient’s issue.
Measurable
how will I measure the progress? How will I know it is achieved?
Actionable/Attainable
is the goal reasonable and achievable?
Can this really happen?
Set realistic goals for your patient’s physical , cognitive, social and environmental factors.
Realistic
why achieving this goal is important?
Establish goals in partnership with your patient.
Timed
When the goal will be achieved? Set a deadline.
SMART Goals - Short Term Goals
Usually established weekly or every 2 weeks
Provide guidance to the patient
Allow logical progression of the rehab
Aim to guide patients towards long term goals
After 2 weeks, progress of patient is re assessed and the goals can be adjusted.
SMART Goals - Long Term Goals
Can be achieved in longer period that could also be 6 months.
Progress Note - Continuation Sheet
What you do on a daily basis with a patient, legal document.
Important to track day to day progression.
Needed if there is a change of therapists.
To remember what was done in the previous session.
