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S O A P notes

The four stages of patient treatment notes

Please start this sequence with Subjective

To help recognition of these stages, each the four parts have been colour-coded to tie them to the relevant sections of the modules

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Diagnosis:

collecting point

please make a note the diagnosis number that appears here and click the 'next' button

    S O A P

What did your patient say to you?
VAS scale

Start of treatment

Subjective notes

What did the patient say?

Provide as much detail as you can and describe the patients one words about themselves in terms of their function, disability, symptoms and history. Also include information from any family or caregivers and, if specific phrasing is used, enclose this in quotation marks. This will allow you or a future therapist to document the patients perception of their condition precisely and how it relates to their progress in rehabilitation, functional performance or quality of life.

Dont:

  • Pass judgement on a patient e.g. "Patient is over-reacting again".
  • Document irrelevant information e.g. patient complaining about previous therapist.

essentially...

  • What did the patient say?
  • What did the caregiver say?
  • Any documentation from other health professionals?
  • What was the VAS scale?

Subjective

 


Name of patient:           

Complaint:            

VAS:            

  continue to:

 

 

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    S O A P

Objective summary

What was your Diagnosis number? What did you observe during the assessment?

 

Completing the objective stage

What did you observe during the treatment?

Objective notes

Things to observe:

Here, we outline the objective results of your assessment, the progress towards functional goals and any treatments performed. Include details of any interventions, as well as frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or carers.

Try to avoid:

  • Giving no detail
  • Summary detail such as: "ROM exercises given"

essentially, note:

  • range of movement (split into passive and active)
  • muscle strength
  • neurological assessment
  • gait
  • function

Objective summary

(paste below): Diagnosis number/name:           
Home exercise (given Y/N):           

choose your D number to proceed to treatment:

 

 

       
    SO A P

Analysis: what did you discover?

What did you discover?

This is potentially the most important legal note because this is the therapists professional opinion in light of subjective and objective findings. It should explain the reasoning behind all decisions taken and clarify and support the analytical thinking behind the problem-solving process. How you arrived at the stated goals should be indicated, as well as any factors that may require modification, such as frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:

  • The assessment is too vague e.g. "Patient is improving"
  • Little insight is provided.

Essentially:

  • document the diagnosis you arrived at
  • include causes of the diagnosis
  • Red flag anything to be aware of (we need to treat patient holistically) note any inconsistencies

Analysis

(to come):           

 

 

       
    SOA P

Plan notes for what is needed

To do list

See notes alert


What is needed:

The final component of the note is used to outline the plan for future sessions. The therapist should report on what the patient's Home exercises will be, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

Common errors:

  • The upcoming plan is not indicated.
  • Vague description of the plan e.g. "Continue treatment".

Essentially:

  • When is the next appointment
  • What will you do at that appointment
  • Any actions needed before the next appointment? (eg get crutches from next village)

  might need a reminder system here for either a diary system or an 'alarm clock' signal when imminent also an onward referral or discharge tab(? )

Plan

(to come):           

 

 

       
SOAP

 

! Checked

...something here to finish the SOAP process and review it... also need a (separate) landing page for previous patients needing new treatment. however the latter would need to ensure the old record cannot be edited, simply viewed and then added to via new fields (am assuming? )...

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