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Evaluation SOAP Notes.

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Presentation on theme: "Evaluation SOAP Notes."— Presentation transcript:

1 Evaluation SOAP Notes

2 HOPS History: a series of questions asked to determine nature and location of injury Observation: A visual examination of the injury Palpation: A hands-on approach where examiner feels for deformity or other abnormal findings Stress tests: A series of tests to check range of motion and degree of function of tissues at a joint

3 SOAP Note Subjective: Objective: Assessment: Plan of Action:
Detailed information about the history of injury and athlete; chief complaints, sign, and symptoms Objective: Information that is record of test measurements; data gained from inspection Assessment: Identification of problem; determine injury; severity of injury Plan of Action: Treatment; Rehabilitation; Referrals

4 SOAP Note Writing Format
Name of Athlete: Date of Examination: Date of Injury: Place of Injury: S: O: A: P: SOAP

5 Subjective Findings Subjective is the oral section of the evaluation; what the patient or witnesses tell you. Ask these questions: Was there a previous injury? How did it happen? When did it happen? What did you feel? How do you feel? What is the type of pain? Where does it hurt? Did it make a sound? * Ask for a witness if the person is incapable of answering

6 Objective Findings Objective is the visual and the hands-on part of the evaluation. Look for the following: Swelling Deformity-protrusions Ecchymosis-Discoloration Symmetry Gait-Walk Scars Facial expressions Bleeding Depressions ROM Stress Test Results

7 Objective Findings Perform Palpations
Check anatomical structures to determine points of pain Check for abnormalities Preform special test or stress tests to assess severity

8 Active Listening Skills
1. Face the speaker—lean slightly forward 2. Maintain eye contact 3. Minimize external/internal distractions 4. Respond appropriately 5. Focus solely on what the speaker is saying 6. Keep an open mind 7. Avoid giving advice until you have completely evaluated injury 8. Don’t interrupt 9. Stay engaged in the interview

9 Extras! Review your notes with the athlete after you have completed your evaluation! The athlete’s well-being WILL depend on the accuracy and thoroughness of your Soap! Ask probing questions and record accurately! This is a medical and legal document and will be used in the court of law if needed.

10 Stress Tests of the Ankle/Foot
Anterior Drawer Talar Tilt Kleiger’s Tap/Bump Test Squeeze Test Thompson’s Test Homan’s Sign

11 Anterior Drawer Steps: Tests For:
Athlete is sitting over the edge of the table with the knee bent Examiner stabilizes the lower leg with one hand (around the tibia/ fibula) & cups the calcaneus with the forearm supporting the foot in slight plantar flexion (~ 20° ) and slight inversion (few degrees) Examiner draws the calcaneus & talus anteriorly and slightly medially Tests For: ATF sprain – positive is pain and laxity over the ATF ligament.

12 Talar Tilt Steps: Test For:
Athlete is sitting with his/her legs over the edge of the table Examiner grasps the calcaneus with one hand & stabilizes the lower leg with the other hand Examiner provides inversion stress rolling the calcaneus inward while the ankle is in neutral Examiner provides an inversion stress by rolling the calcaneus inward while the ankle is in the plantar flexed position Examiner provides an eversion stress rolling the calcaneus outward while the ankle is neutral Test For: Inversion Stress: CF ligament and possibly the ATF and PTF. Eversion Stress: Deltoid ligament

13 Kleiger’s (External Rotation) Test
Steps: Athlete is sitting with his/her legs over the edge of the table Examiner stabilizes the lower leg with one hand Examiner grasps the medial aspect of the foot while supporting the ankle in neutral and externally rotates Examiner dorsiflexes and externally rotates the foot Tests For: DF: test for syndesmosis involvement Neutral: test for injury to the deltoids

14 Thompsons Test Steps: Tests For:
Athlete is prone with his/her knee extended Examiner squeezes the calf musculature while observing for ankle plantar flexion Tests For: Ruptured Achilles Tendon: positive test is the ankle will not PF when squeezed

15 Tap Test/Bump Test Steps: Test For:
Athlete is sitting or lying supine, with the involved foot off the end of the table & the knee straight Examiner stabilizes the lower leg with one hand & bumps the calcaneus with the other hand Examiner bumps the calcaneus 2–3 times with progressively more force Test For: Fractures: pain emanating from the fx of calcaneus, talus, tibia, or fibula

16 Squeeze Test/Compression
Steps: Athlete is sitting or lying with his/her knee extended Examiner cups his/her hands behind the tibia & fibula, away from the site of pain Examiner compresses the tibia & fibula, gradually adding more pressure Test For: Fracture: pain is elicited in the area away from the compression

17 Homan’s Sign Steps Test For:
Athlete is sitting or supine with the knee extended Examiner passively dorsiflexes the foot while knee is extended Examiner squeezes the calf muscles Test For: DVT (Deep Vein Thrombosis): Pain in the calf

18 Rehabilitation Phases
There are 6 phases of the rehabilitation process. The different phases can go on concurrently, however you must be able to complete the prior phase to add in the next phase. Therapeutic: is the healing action; of or relating to the treatment of disease or disorders by remedial agents or methods

19 Phase I: Pain Management
Time immediately following injury or surgery which movement is limited in the affected part to ease pain How To: Pain control - Medication Control inflammation RICE

20 Phase II: ROM Time when therapeutic action is initiated including joint range-of-motion, mobility and flexibility exercises How To: PROM- passive rom AAROM- active assisted rom AROM- active rom Flexibility

21 Phase III: Proprioception
The phase where the body relearns the ability to sense the position of its limbs during movement and in space; includes balance and coordination How To: Balance exercises Coordination exercises

22 Phase IV: Resistive Training
The phase to increase muscular strength How To: Emphasize the injured area, but maintain whole body strength

23 Phase V: Endurance This phase is for both the cardiovascular and muscle systems to be able to perform work over a period of time How To: High amount of repetitions with low weight is muscular endurance Full-body cardiovascular endurance

24 Phase VI: Sport Specific
Is the phase where the athlete mimics specific sport-like or functional activities during program. This will progress to full resumption of activity. How to: Gradual resumption of activity Limited or restrictive moving towards full resumption

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