1. The S.O.A.P. Note Documenting Injuries
Injury Evaluation
The S.O.A.P. Note
Documenting Injuries

2. Bell Work
Think back to a specific day on a family vacation when you were little.
What do you remember?
What people where present?
What did you do?
What was the highlight of the day?
Do you think you would remember more if you had a journal entry of the day?

3. Think-Pair-Share With a partner, share your experience.
What would the advantages be if you wrote down what you did, and mentioned more of the specifics?

4. Bell Work
Grab your binder, supply boxes, and white boards from the cabinet
Grab your worksheets from the front table
Discuss in your group 3 reasons it is important to write down information gathered during the evaluation (HOPS) process. Write them down on your white boards

5. Objectives Identify SOAP Identify where information goes into SOAP
Identify the importance of documentation of the evaluation (HOPS) process
Provide a report on the findings of an injury evaluation

6. SOAP Note S – Subjective O – Objective A – Assessment P – Plan
The SOAP note format provides a standard format for recording injury information
S – Subjective
O – Objective
A – Assessment
P – Plan

7. SOAP Note vs. HOPS What was the purpose of HOPS?
A system of injury evaluation
How does it differ from a SOAP note?

8. Terminology S= Subjective Findings
Record any findings that the athlete, coach, teammate or parents says about how the injury was sustained.
History (Hx)
Have you had this type of injury before?
Mechanism of injury
How did it happen?
Symptoms
What do you feel?

9. Terminology O=Objective Findings
Record anything that was observed or measured during the evaluation
Observations
Swelling? Deformity? Limping?
Palpations
Crepitus? Deformity?
Special Testing
Laxity? Decreased ROM?

10. Terminology A=Assessment
What the evaluator’s opinion or diagnosis is of the injury
Grade 2 sprain of R ATF ligament
Always include the degree of injury, along with noted side
Incorrect: Sprained ankle

11. Terminology P=Plan First aid treatment
AT’s disposition to injury (ie referral, f/u next day)
Recording of short term and long term goals for the injury
Short Term: Rest, Ice, begin ROM exercises
Long Term: Progress from bike to ellipical to treadmill over the next 4 weeks.

12. Why use a SOAP Note?

13. Documentation You cannot remember every detail.
SOAP notes provide an organized way to keep good records of an athlete.
It is a good way to record an individual’s progress over time.
It can be used as evidence to protect you in case of a lawsuit.

14. Now what? You filled out a SOAP note document for an injured athlete.
Do you stop at the day of injury?
SOAP notes are used throughout the entire recovery process until the athlete has been cleared or has resumed full activity.

15. Progress Notes
Routinely written after each progress evaluation done throughout the course of the rehab program
Info should concentrate on type of tx and patient’s response to tx
Progress made towards short/long term goals
Changes in previous tx plan and new course of tx over the next several days

16. Where does it go? Determine if it is Subjective, Objective, Assessment or Plan.
Gradual swelling
Tingling pain
Ice for 15 min.
Begin ROM rehab
Right ankle sprain
Limping
Tender to touch
Concussion
“Giving out” feeling
Objective
Subjective
Plan
Assessment
Subjective & Objective

17. Where does it go? Determine if it is Subjective, Objective, Assessment or Plan.
Holding elbow
Grade III R. ACL Sprain
Felt/heard ‘pop’
CWP 20’
ROM exercises for ankle
Discoloration
PEARL
Sharp, shooting pain
Objective
Assessment
Subjective
Plan

18. Where does it go? Determine if it is Subjective, Objective, Assessment or Plan.
Varus Stress Test
P/T on fibular head
Decreased strength
Throbbing pain
Patellar Tendonitis
Ice bag 15’
Progress from walking to running in 2 weeks
Objective
Subjective
Assessment
Plan

19. SOAP Note
Read through the worksheet and record your findings on the SOAP note