Standard 11 Rehab Careers S.O.A.P. Notes

Standard 11 Compare and contrast physiological responses of patients of differing ages, current health status, and presence of acute and/or chronic diseases. For example, compare the response of a healthy elderly patient with a fractured femur to an overweight adolescent with the same fracture. Explain how one would differentiate treatment to meet varying conditions.

Physiological Responses TermDefinition Acute physiological response An immediate change (increase or decrease) in one or more of the bodies systems in response to a stimuli Chronic physiological adaptations Changes to one or more of the bodies systems as result of long term consistent stimulus, such as exercise

Evaluation All new patients/injuries/illnesses/diseases need a thorough evaluation. Different HCP use different tools to accomplish this. Most Rehab Careers Professionals use SOAP notes.

S.O.A.P. Notes What are SOAP notes? S.O.A.P. notes are a concise format of effectively documenting the initial evaluation and progress notes for the injured patient. They are part of a system designed to record subjective and objective findings and to document the immediate and future treatment plan for the patient.

Which health care professionals use SOAP notes? Athletic Trainers Chiropractors Physical Therapists Other health care professionals S.O.A.P. Notes

What is the benefit of using SOAP Notes? The standardization of a note-taking format makes it easier to transfer patients between providers. S.O.A.P. Notes

(CC) = “Chief Complaint”: What is written in this section? The first thing the patient tells you. Example(s): If the patient comes into the training room and says, “I hurt my arm” or “my knee is really sore,” you would write: “CC: Right arm pain” or “CC: Left knee soreness.”

What is the purpose of this section? It makes it easier for the HCP, when looking back through the notes or trying to remember what their original complaint was, to easily identify what area of the body has been injured. (CC) = “Chief Complaint”:

(S) = Subjective: What is described in this section? This part of the notes is made up of the subjective statements provided by the injured patient. The patient tells the HCP about the injury relative to the history or what he/she felt.

This section is designed to gain information from the patient relative to: The date, time, mechanism, and site of injury. The type and course of the pain (i.e. is it getting better or worse). The degree of disability. What does this mean? Difficulty walking or performing normal everyday tasks.

Possible Questions: How did this injury occur? Where do you feel pain? When did the injury occur/ When did it start hurting? Are you having trouble walking/writing/ getting dressed/etc.? Have you injured this area before? Did you hear or feel anything pop or tear?

(O) = Objective: What is described in this section? The objective portion documents information that the HCP gathers during the evaluation.

Findings will include: Visual inspection Palpation Assessment of active, passive, and resistive motion Additional findings such as posture, presence of deformity or swelling, and location of point tenderness will also be noted here.

Visual Analog Scale = Have the patient rate their pain level on a scale of zero to 10: “10” being the worst pain they can imagine “0” being no pain at all

(A) = Assessment: What is described in this section? The HCP’s professional opinion about the nature of the injury. What is important to remember about this section? Only licensed physicians are allowed to make the final diagnosis of an injury.

Example(s) of what may be written in this section: “ Grade II Right lateral ankle sprain” “Grade II Tear of the Lateral Head of the Gastrocnemius” “Cervical Spine Sprain/Strain post- MVA” “Right Subacromial Bursitis”

(P) = Plan: What is described in this section? Your plan for treatment of the patient’s injury. This section should include the first aid treatment rendered (e.g. application of splint, wrap, or crutches) to the patient and the intentions for future treatment.

This section should also include: Doctor referrals Short-term goals Long-term goals When the patient will return for treatment