ROP Sports Medicine:

LECTURE #5

S.O.A.P. 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 athlete.

They are part of a system designed to record subjective and objective findings and to document the immediate and future treatment plan for the athlete.

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 athlete tells you.

Example(s): If the athlete 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 trainer, 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 athlete.

The athlete tells the Athletic Trainer about the injury relative to the history or what he/she felt.

This section is designed to gain information from the athlete 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 Athletic Trainer 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 athlete 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 Athletic Trainer’s professional opinion about the nature of the injury.

What is important to remember about this section? As a student you are not 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 athlete’s injury.

This section should include the first aid treatment rendered (e.g. application of splint, wrap, or crutches) to the athlete and the intentions for future treatment.

This section should also include:

Doctor referrals Short-term goalsLong-term goalsWhen the athlete will return for

treatment

ANY QUESTIONS????