Subjective, and Objective Portions of the SOAP Note

Question 1

How is information organized in a SOAP Note?

Answer 1

by SOURCE of information

*unlike type of information like in a Pt/Client note

Question 2

What does the “S” portion of the SOAP note stand for?

Answer 2

S = Subjective

Question 3

What type of information is found in the Subjective Section?

Answer 3

Any information gathered from the patient, family, care giver, medical record pertaining to the present problem
Any information you collect that is not a result of test you conduct/measure
ANYTHING A PATIENT SAYS!!

Question 4

What is the importance of the Subjective Section?

Answer 4

Helps justify to third-party payers by establishing goals for this patient based on prior level of function

Question 5

6 Things listed in the Subjective Portion include…

Answer 5

(1) Demographic information
(2) Recent or past surgeries
(3) Past medical history
(4) Present condition/disease
(5) Medical test results
(6) Patient medications

Question 6

Specifics found in the Subjection Portion

Answer 6

(1) Current condition/chief complaints
(2) PLOF
(3) Patient’s goals
(4) Social history
(5) Employment status
(6) Living environment
(7) Habits/Hobbies
(8) Medical/surgical/family health history
(9) Current functional status/deficits
(10) Medications
(11) Patient’s response to treatment/interventions

Question 7

6 Tips to writing the subjective

Answer 7

• Keep it as brief, but complete as possible
• Only reference the pt once and from that point forward it’s understood the information was reported by the pt
• Use correct spelling
• Full sentences are not necessary as long as the idea is complete
• Use verbs to indicate the information is from the pt, not the medical chart (such as States, describes, denies, indicates, c/o)
• You may quote the pt directly, but be sure to use quotation marks

Question 8

A subjective portion is required for what type of notes?

Answer 8

• Initial Eval
• Daily Note
• Progress Note
• Discharge

Question 9

What does the “O” portion of the SOAP note stand for?

Answer 9

O = Objective

Question 10

What type of information is found in the Objective Section?

Answer 10

• Results of any tests and measures
• Objective observations made by the therapist
• Measurable and objective data is repeatable
• Often this information is compared note to note to demonstrate progress, or lack there of

Question 11

What is an objective observation?

Answer 11

Statement that is only objective (walks with limp)

Question 12

What is an objective assessment?

Answer 12

Statement that describes an objective observations

Question 13

Where do we record what we did with the patient? (i.e. “See Ther Ex Flowsheet”)

Answer 13

Objective

Question 14

7 Types of Systems Review

Answer 14

• Cardiovascular/pulmonary system
• Integumentary system
• Musculoskeletal system
• Neuromuscular system
• Communication style or abilities
• Affect and cognition
• Learning style/barriers
• Educational needs

Question 15

Objective measures are ______ and repeatable.

Answer 15

Measurable

Question 16

Why do we do a systems review?

Answer 16

To ensure the patient is appropriate for therapy

Question 17

4 Tips to writing the objective

Answer 17

• Keep it as brief, but complete as possible
• Use correct spelling
• Full sentences are not necessary as long as the idea is complete
• Use tables to organize data

Question 18

4 Common Mistakes to Avoid when writing the Objective Section

Answer 18

• Incomplete Data
• Failure to state affect anatomy
• Failure to state in measurable terms
• Failure to state type measured

Question 19

A subjective portion is required for what type of notes?

Answer 19

• Initial Eval
• Daily Note
• Progress Note
• Discharge