Swedish quiz 4 - Record keeping Flashcards
SOAP
Define letters
S- subjective
O - objective
A - assessment/action
P - plan
Subjective
What they say either direct quote “Sore today” or
therapist words client c/c sore all over
Objective
What you see (therapist) feel, or measure
Measure range of motion
Action or assessment
And how they responded
What you did and what happened
Plan
What to do next time
In regard to record keeping, what information should be included in the subjective data
what the client says
current concerns
What should be considered in the plan information
what to do for future treatment
What information needs to be gathered for the initial intake proceedure
basic personnal data
injuries/diseases/conditions
medications
prior massage
How do you aquire objective data on your client
what you
see
feel
measure
How often do you chart your client’s progress
every visit
How do you maintain the integrity of client charts?
keep locked away
out of site
Why do massage practictioners keep records on their clients?
track progress
When making a functional assessment what are you looking for?
ability to do activities of daily living
body language
Explain the A in the SOAP note charting process
assessmet/action
what was done and how they responded
R
Right
L
Left
R UE
Right upper extremity
L UE
left Upper Extremity
R UE
right upper extremity
L UE
left upper extremity
tx
treatment
LB
lower back
LBP
lower back pain
PN
pain
HA
headache
pt
patient
C/C
chief complaint
C/O
complains of
w/o
without
up arrow
increases
down arrow
decreases
status quo
no changes
c with a line above it
with
