Introduction to SOAP Notes

Components

Problem S = subjective O = objective A = Assessment P = Plan

Problem (or Diagnosis)

Medical diagnosis (e.g. adhesive capsulitis) or problem (e.g. frozen shoulder) Problem includes (as applicable):
Recent

or past surgeries Past conditions or diseases Present conditions or diseases Medical test results Referral mechanism

Examples
1.

2.

Dx: (L) hemiplegia resulting from craniotomy for removal of tumor on 9-12-2004. Hx of htn. Referring physician: Dr. Alexad. 58-yr-old w/ (L) BK amputation on 12-17-2004, 20 PVD. Hx of diabetes. Referring physician: Dr. Ollandern.

Subjective

Things the patient (or significant other) tells us about his/her:

Condition/chief

complaint Functional status/activity level Cultural and religious beliefs Employment status Living environment General health status Social/health habits Family health history

Subjective (contd)
Medical/surgical Medications Growth

history

& development other clinical tests Response to treatment intervention Goals Or anything else relevant and significant to the patients case or present condition

Subjective: Things to consider

Use of the term patient Organization; concise Verbs: states, describes, denies, indicates, c/o Quoting the patient verbatim
To

illustrate confusion or memory loss To illustrate denial To describe pain

Subjective: Example 1. Information from the patient

S: Current condition: c/o pain (R) ankle when (R) ankle is in dependent position. Denies any other pain or dizziness. States fell at home and felt (R) ankle pop. Living environment: Describes 3 steps w/o a handrail at entrance to the home. Denies use of crutches PTA. Social/health habits: States played basketball 3x/wk PTA. Patient goals: Pts goal is to play basketball again.

Subjective: Example 2. Information from the family

S: (All of the following information was taken from the pts daughter. Pt. is unable to verbalize 2 to aphasia.) Functional status/activity level: Pt amb indep PTA.

Subjective: Example 3. Combining

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

Objective

Things we find during the examination:

Systems

review Tests and measures Functional skills Medical history when taken from the medical record

Objective: Things to Consider

Organize and categorize

Use

headings, caps & underlining Use tables or charts Use flow sheets

Be specific
State

the affected anatomy State information in measurable terms State type (e.g. transfer to where from where?)

Objective: Example
O: HISTORY: CHF, COPD. SYSTEMS REVIEW: Cardiovascular/ pulomonary system: BP 140/85. HR 90. RR 20. Integumentary system: skin thin & fragile bilat LEs. Musculoskeletal system: gross symmetry impaired in LEs standing. Neuromuscular system: Gait unimpaired. Transfers impaired. Communication: Age appropriate and unimpaired. Affect: emotional/behavioral responses unimpaired. Cognition: level of consciousness unimpaired. Orientation to person, place and time impaired TESTS AND MEASURES: AROM: WNL t/o UEs and LEs except 1200 (L) shoulder flexion. Strength: 5/5 t/o UEs

Assessment

Your professional opinion PT Diagnosis

Specific

practice pattern or patterns (primary and secondary) Inconsistencies Further testing needed Consultations and/or referrals w/ other practitioner(s) needed

Assessment (contd)

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

environment Patients condition prior to onset Concurrent illnesses or medical conditions (co-morbidities)

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

Plan

Where do you want to go and how are you going to get there? Goals:
Long-term Short-term

Intervention Discharge plans

Plan: Long-Term Goals

Expected outcomes Functional; behaviorally stated Includes: Who (who will exhibit the behavior) Behavior (what actions will the person exhibit) Conditions (what is needed for the person to perform the behavior) Degree (a measure by which you will determine success) Example: P: Long-term goal: Indep amb (behavior) w/ a walker (condition) FWB (L) LE (another condition) for at least 150 ft x 2 (degree) on level surfaces & on 1 step elevation (more conditions) within 1 mo (degree) to allow patient (who) to amb around her home (function).

Plan: Short-Term Goals

Anticipated goals The interim steps needed to achieve the long-term goals Also include the
Who Behavior Condition Degree

Plan: Short-Term Goals Examples

Examples showing pt progress toward long-term goal of Indep amb w/ a walker FWB (L) LE for at least 150 ft x 2 on level surfaces & on 1 step elevation within 1 mo to allow patient to am around her home:
Short-term goal: Pt will amb 30 ft x 2 in // bars 10% PWB (L) LE within 3 days w/ mod + 1 assist Short-term goal: Pt will amb w/ walker 50 ft x 2 10% PWB (L) LE within 1 week w/ min +1 assist

Plan: Interventions

Must include:

Frequency (per day or per week) that pt will be seen Interventions Location of treatment (bedside, in dept., at home) Treatment progression Plan for further assessment or reassessment Plans for discharge Patient & family education Equipment needs or equipment ordered Referrals to other services

May also include:

Plan: Interventions - Example

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

Note Writing and the Process of Clinical Decision-Making

SOAP Note Patient/Client Management Process EXAMINATION Patient/Client Management Note History Systems Review Tests & Measures Diagnosis Prognosis Expected Outcomes Anticipated Goals Interventions, including patient education Problem Subjective Objective Assessment (includes Diagnosis and Prognosis) Plan of Care (Expected Outcomes, Anticipated Goals and Interventions, including patient education)

EVALUATION

PLAN OF CARE

OUTCOMES