Introduction to SOAP Introduction to SOAP NotesNotes

ComponentsComponents

ProblemProblem SS = subjective = subjective OO = objective = objective AA = Assessment = Assessment PP = Plan = Plan

Problem (or Diagnosis)Problem (or Diagnosis)

Medical diagnosis (e.g. Medical diagnosis (e.g. adhesive capsulitis) or problem adhesive capsulitis) or problem (e.g. frozen shoulder)(e.g. frozen shoulder)

Problem includes (as Problem includes (as applicable):applicable): Recent or past surgeriesRecent or past surgeries Past conditions or diseasesPast conditions or diseases Present conditions or diseasesPresent conditions or diseases Medical test resultsMedical test results Referral mechanismReferral mechanism

ExamplesExamples

1.1. Dx: (L) hemiplegia resulting Dx: (L) hemiplegia resulting from craniotomy for removal of from craniotomy for removal of tumor on 9-12-2004. Hx of htn. tumor on 9-12-2004. Hx of htn. Referring physician: Dr. Referring physician: Dr. Alexad.Alexad.

2.2. 58-yr-old 58-yr-old ♂♂ w/ (L) BK w/ (L) BK amputation on 12-17-2004, 2amputation on 12-17-2004, 200 PVD. Hx of diabetes. Referring PVD. Hx of diabetes. Referring physician: Dr. Ollandern.physician: Dr. Ollandern.

SubjectiveSubjective

Things Things the patient (or significant the patient (or significant other) tells usother) tells us about his/her: about his/her: Condition/chief complaintCondition/chief complaint Functional status/activity levelFunctional status/activity level Cultural and religious beliefsCultural and religious beliefs Employment statusEmployment status Living environmentLiving environment General health statusGeneral health status Social/health habitsSocial/health habits Family health historyFamily health history

Subjective (cont’d)Subjective (cont’d)

Medical/surgical historyMedical/surgical history MedicationsMedications Growth & developmentGrowth & development other clinical testsother clinical tests Response to treatment Response to treatment

interventionintervention GoalsGoals Or – anything else relevant and Or – anything else relevant and

significant to the patient’s case or significant to the patient’s case or present conditionpresent condition

Subjective: Things to considerSubjective: Things to consider

Use of the term “patient”Use of the term “patient” Organization; conciseOrganization; concise Verbs: states, describes, denies, Verbs: states, describes, denies,

indicates, c/oindicates, c/o Quoting the patient verbatimQuoting the patient verbatim

To illustrate confusion or memory To illustrate confusion or memory lossloss

To illustrate denialTo illustrate denial To describe painTo describe pain

Subjective: Example 1. Subjective: Example 1. Information from the patientInformation from the patient SS: : Current conditionCurrent condition: c/o pain (R) : c/o pain (R)

ankle when (R) ankle is in dependent ankle when (R) ankle is in dependent position. Denies any other pain or position. Denies any other pain or dizziness. States fell at home and dizziness. States fell at home and felt (R) ankle “pop.” felt (R) ankle “pop.” Living Living environmentenvironment: Describes 3 steps w/o : Describes 3 steps w/o a handrail at entrance to the home. a handrail at entrance to the home. Denies use of crutches PTA. Denies use of crutches PTA. Social/health habitsSocial/health habits: States played : States played basketball 3x/wk PTA. basketball 3x/wk PTA. Patient goalsPatient goals: : Pt’s goal is to play basketball again. Pt’s goal is to play basketball again.

Subjective: Example 2. Subjective: Example 2. Information from the familyInformation from the family

SS: (All of the following : (All of the following information was taken from the information was taken from the pt’s daughter. Pt. is unable to pt’s daughter. Pt. is unable to verbalize 2verbalize 2°° to aphasia.) to aphasia.) Functional status/activity levelFunctional status/activity level: : Pt amb indep PTA…. Pt amb indep PTA….

Subjective: Example 3. Subjective: Example 3. CombiningCombining

SS: : Current conditionCurrent condition: Pt c/o SOB : Pt c/o SOB immediately post examination … immediately post examination … Medical/surgical hxMedical/surgical hx: Husband : Husband states pt has hx COPD for 10 states pt has hx COPD for 10 yrs …yrs …

ObjectiveObjective

Things Things wewe find during the find during the examination:examination: Systems reviewSystems review Tests and measuresTests and measures Functional skillsFunctional skills Medical history when taken from Medical history when taken from

the medical recordthe medical record

Objective: Things to ConsiderObjective: Things to Consider

Organize and categorizeOrganize and categorize Use headings, caps & underliningUse headings, caps & underlining Use tables or chartsUse tables or charts Use flow sheetsUse flow sheets

Be specificBe specific State the affected anatomyState the affected anatomy State information in measurable State information in measurable

termsterms State type (e.g. transfer to where State type (e.g. transfer to where

from where?)from where?)

Objective: ExampleObjective: Example

OO: HISTORY: CHF, COPD. : HISTORY: CHF, COPD. SYSTEMS REVIEW: SYSTEMS REVIEW: Cardiovascular/ Cardiovascular/ pulomonary systempulomonary system: BP 140/85. HR 90. : BP 140/85. HR 90. RR 20. RR 20. Integumentary systemIntegumentary system: skin thin & : skin thin & fragile bilat LEs. fragile bilat LEs. Musculoskeletal systemMusculoskeletal system: : gross symmetry impaired in LEs standing. gross symmetry impaired in LEs standing. Neuromuscular systemNeuromuscular system: Gait unimpaired. : Gait unimpaired. Transfers impaired. Transfers impaired. CommunicationCommunication: Age : Age appropriate and unimpaired. appropriate and unimpaired. AffectAffect: : emotional/behavioral responses emotional/behavioral responses unimpaired. unimpaired. CognitionCognition: level of : level of consciousness unimpaired. Orientation to consciousness unimpaired. Orientation to person, place and time impaired … person, place and time impaired … TESTS AND MEASURES: TESTS AND MEASURES: AROMAROM: WNL t/o : WNL t/o UEs and LEs except 120UEs and LEs except 12000 (L) shoulder (L) shoulder flexion. flexion. StrengthStrength: 5/5 t/o UEs … : 5/5 t/o UEs …

AssessmentAssessment

Your professional opinionYour professional opinion PT DiagnosisPT Diagnosis

Specific practice pattern or Specific practice pattern or patterns (primary and secondary)patterns (primary and secondary)

InconsistenciesInconsistencies Further testing neededFurther testing needed Consultations and/or referrals w/ Consultations and/or referrals w/

other practitioner(s) neededother practitioner(s) needed

Assessment (cont’d)Assessment (cont’d)

Prognosis: predict the level of Prognosis: predict the level of improvement in function and the improvement in function and the amount of time needed to reach amount of time needed to reach that level. that level.

Consider:Consider: Living environmentLiving environment Patient’s condition prior to onsetPatient’s condition prior to onset Concurrent illnesses or medical Concurrent illnesses or medical

conditions (co-morbidities)conditions (co-morbidities)

Assessment: Example Assessment: Example

AA: DIAGNOSIS: Pt’s : DIAGNOSIS: Pt’s ↓ ROM & strength ↓ ROM & strength (L) wrist cause pt difficulty in ADLs (L) wrist cause pt difficulty in ADLs such as eating and writing. Pt’s work such as eating and writing. Pt’s work involves typing over 50% of the time involves typing over 50% of the time and pt is unable to type w/o pain. and pt is unable to type w/o pain. Practice patternPractice pattern: Musculoskeletal G: : Musculoskeletal G: Impaired joint mobility, muscle Impaired joint mobility, muscle performance and ROM associated performance and ROM associated w/ fracture.w/ fracture. PROGNOSIS: Pt. has good rehab PROGNOSIS: Pt. has good rehab potential; will progress well with PT potential; will progress well with PT and return to work w/ full ROM and and return to work w/ full ROM and strength and w/o pain in six weeks.strength and w/o pain in six weeks.

PlanPlan

Where do you want to go and Where do you want to go and how are you going to get there?how are you going to get there?

Goals:Goals: Long-termLong-term Short-termShort-term

InterventionIntervention Discharge plansDischarge plans

Plan: Long-Term GoalsPlan: Long-Term Goals

Expected outcomesExpected outcomes Functional; behaviorally statedFunctional; behaviorally stated Includes:Includes:

Who (who will exhibit the behavior)Who (who will exhibit the behavior) Behavior (what actions will the person exhibit)Behavior (what actions will the person exhibit) Conditions (what is needed for the person to Conditions (what is needed for the person to

perform the behavior)perform the behavior) Degree (a measure by which you will determine Degree (a measure by which you will determine

success)success) Example: Example:

PP: : Long-term goalLong-term goal: “Indep amb (behavior) w/ a : “Indep amb (behavior) w/ a walker (condition) FWB (L) LE (another walker (condition) FWB (L) LE (another condition) for at least 150 ft x 2 (degree) on level condition) for at least 150 ft x 2 (degree) on level surfaces & on 1 step elevation (more conditions) surfaces & on 1 step elevation (more conditions) within 1 mo (degree) to allow patient (who) to within 1 mo (degree) to allow patient (who) to amb around her home (function).”amb around her home (function).”

Plan: Short-Term GoalsPlan: Short-Term Goals

Anticipated goalsAnticipated goals The interim steps needed to The interim steps needed to

achieve the long-term goalsachieve the long-term goals Also include theAlso include the

WhoWho BehaviorBehavior ConditionCondition DegreeDegree

Plan: Short-Term Goals - Plan: Short-Term Goals - ExamplesExamples Examples showing pt progress Examples showing pt progress

toward long-term goal of “Indep amb toward long-term goal of “Indep amb w/ a walker FWB (L) LE for at least w/ a walker FWB (L) LE for at least 150 ft x 2 on level surfaces & on 1 150 ft x 2 on level surfaces & on 1 step elevation within 1 mo to allow step elevation within 1 mo to allow patient to am around her home”:patient to am around her home”: Short-term goalShort-term goal: Pt will amb 30 ft x 2 : Pt will amb 30 ft x 2

in // bars 10% PWB (L) LE within 3 days in // bars 10% PWB (L) LE within 3 days w/ mod + 1 assistw/ mod + 1 assist

Short-term goalShort-term goal: Pt will amb w/ walker : Pt will amb w/ walker 50 ft x 2 10% PWB (L) LE within 1 week 50 ft x 2 10% PWB (L) LE within 1 week w/ min +1 assistw/ min +1 assist

Plan: InterventionsPlan: Interventions

Must include:Must include: Frequency (per day or per week) that pt will be Frequency (per day or per week) that pt will be

seenseen InterventionsInterventions

May also include:May also include: Location of treatment (bedside, in dept., at Location of treatment (bedside, in dept., at

home)home) Treatment progressionTreatment progression Plan for further assessment or reassessmentPlan for further assessment or reassessment Plans for dischargePlans for discharge Patient & family educationPatient & family education Equipment needs or equipment orderedEquipment needs or equipment ordered Referrals to other servicesReferrals to other services

Plan: Interventions - ExamplePlan: Interventions - Example

Intervention planIntervention plan: BID in dept.: amb : BID in dept.: amb training w/ a walker beginning w/ training w/ a walker beginning w/ 50% PWB (L) LE & progressing wt. 50% PWB (L) LE & progressing wt. bearing & distance as tolerated; bearing & distance as tolerated; transfer training; pt will be given transfer training; pt will be given written and verbal instructions in written and verbal instructions in exercise program to be performed in exercise program to be performed in his room (attached); AAROM his room (attached); AAROM progressing to AROM exercises (L) progressing to AROM exercises (L) knee emphasizing quadriceps knee emphasizing quadriceps functioning.functioning.

Note Writing and the Process Note Writing and the Process of Clinical Decision-Makingof Clinical Decision-Making

SOAP NoteSOAP Note Patient/Client Patient/Client Management Management

ProcessProcess

Patient/Client Patient/Client Management NoteManagement Note

ProblemProblem

SubjectiveSubjective

ObjectiveObjective

EXAMINATIONEXAMINATION HistoryHistory

Systems ReviewSystems Review

Tests & MeasuresTests & Measures

Assessment Assessment (includes Diagnosis (includes Diagnosis and Prognosis)and Prognosis)

EVALUATIONEVALUATION DiagnosisDiagnosis

PrognosisPrognosis

Plan of Care Plan of Care (Expected (Expected Outcomes, Outcomes, Anticipated Goals Anticipated Goals and Interventions, and Interventions, including patient including patient education)education)

PLAN OF CAREPLAN OF CARE Expected Expected OutcomesOutcomes

Anticipated GoalsAnticipated Goals

Interventions, Interventions, including patient including patient educationeducation

OUTCOMESOUTCOMES