SOAP Note Components

• Where does subjective data collection come from

  Patient, patient family/ caregiver, Medical Chart, Other Health Care Providers
• Health Condition includes

  Medical diagnosis, physical therapy diagnosis, loss of function, and new test results
• Subjective answers the question of


  What does the patient have to say?
• Subjective documents


  Patient reaction to interventions provided, new problems or complaints, and pertinent info not previously documented
• Subjective Contains

  Patient status, informed consent, direct quotes, patient's reaction, new problems or new complaint, pertinent info not previously documented
• Patient Status Includes

  Pain rating and description, patient's perception of symptoms, patient's functional abilities, statement that demonstrates cognitive or emotional status, comments related to goal/ outcome
• Informed consent Elements

  Inform patient of care to be provided
• Patient Reaction to Provided Interventions Include

  Behavior of patients pain since last intervention, comments to demonstrate intervention effectiveness, did the pain change, did it improve, get worse, or no change with intervention
• New Complaints Include

  New pain complaints, any new problems with functional activities
• New information includes

  Medical history, environment (lifestyle, home situation, work, school, etc)
• Structure for Subjective

  Infrequent need for subheadings, group similar info together, when documenting a lot of info may use subheadings, eval as guide to use subheadings
• Subheadings of Subjective

  Current condition, patient complaint, living environment, functional status/ activity level, medical/ surgical history, social history, employment status
• Subjective use verbs like

  States, reports, complains of, denies, describes, etc
• Objective answers the question


  What is going on with the physical therapy intervention? How is the patient responding to the intervention?
• Objective includes

  Patient readiness to participate, interventions provided, and patient's response to PT intervention provided
• Objective Structure Goal

  Easily find info, provide logical flow of info
• Documenting Interventions includes

  What intervention was provided, amount, equipment used, parameters, specific treatment area, postitioning, duration, frequency, and rest breaks, anything different from standard practice, time per intervention, total treatment time
• Document Communication with

  supervising PT, health care practitioners, administrator/ case manager, phone conversions
• Document Patient related instruction

  Instruction HEP, Precautions/ restricted activity, education of disease, education of PT procedures, family/ caregiver instruction
• For Physical Agents used document

  Patient position, specific area treated, exact settings used, duration of treatment
• For Fuctional Training document

  Specific activity and assistive/ adaptive devices used
• For Wound Care Document

  Isolation or sterile technique followed and any PPE used, type and amount of dressing, precautions for dressing removal
• Manual Therpay Techniques Document

  Side, joint, and motion, number of reps and time, type of massage, technique performed
• Functional Training Includes

  Balance training, gait, locomotion, transfer training, posture training
• Therapeutic Exercise Document

  Specific activity/ exercise performed, equipment used, patient position, reps, time spent
• Documenting of data collection

  What was measured, what device was used, patient position
• Heart Rate Documentation

  Location, quality, rate
• Respiratory Rate Documentation

  Rate, rhythm, depth, regularity of pattern
• Blood pressure Documentation

  Location; side, systolic over diastolic, indicate when taken
• Vital Signs Documentation

  When taken, patient position; Include HR, BP, RR, O2 Sat
• Quantitative Anthropometric measurements include

  Height, weight, length, girth, BMI
• Muscle Strength Documentation

  Range, what measured, arrange logically
• Muscle Performance Documentation

  Describe abnormal mass, changes in tone, compensatory mechanics
• Pain Documentation

  Non verbal pain response (objective) verbal description (subjective)
• ROM Documentation

  Range, specific joint, arrange logically, use tables/ columns for bilateral, any deviation from standard position
• Functional Outcome Measures Documentation

  Record measurements per the standard of the test being used
• Assistive/ Prosthetic Devices Documentation

  Specify device used, ability to care for device, patient's ability to don and doff device, skin condition related to use of device, safety risk
• Gait, locomotion, and balance documentation

  Indicate Activity, any assistive device, type of surface, distance traveled, amount and type of assistance provided, number of people providing assistance, amount and types of cues, gait pattern, gait deviation, weight bearing status
• Self-Care and Home Management Documentation

  Measurements of physical environments, safety concerns or barriers in home, community and work
• Arousal, mentation, and cognition Documentation

  Changes in patient's state of arousal, mentation, and cognition