The SOAP Note

Question 1

What’s included in Subjective?

Answer 1

MOI, pn, History

Question 2

In subjective what should you find out about pn?

Answer 2

scale (0-10), type of pn, where is pn

Question 3

What does History include in Subjective?

Answer 3

Medical Hx, medication Hx, family Hx, how they slept, what makes it worse or better

Question 4

What’s included in Objective?

Answer 4

gait posture.
deformity, ecchymosis, edema
location, severity
palpation
ROM

Question 5

Antalgic gait?

Answer 5

Gait developed to avoid pain while walking

Question 6

What are you looking for during palpation?

Answer 6

spongy, hard, soft endpts
nodules
Pn

-do not unnecessarily touch before knowing location and severity of injury

Question 7

How will you perform ROM tests?

Answer 7

active ROM - goniometer
passive ROM - goniometer
resisted ( 1-5 scale)
MMT - manual muscle testing (every plane)
special test (ST)
Neuro exam

Question 8

What is the Assesment?

Answer 8

woking diagnosis, possibilities, clinical diagnosis, grade/severity

Question 9

What is the Plan?

Answer 9

initial treatment, referrals, short term goals, long term goals

Question 10

What is the point of a field assessment?

Answer 10

can I transport this athlete safely or not?