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S dot O dot A dot P notes

A walk-through guide

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S dot O dot A dot P

 

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objective

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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

SOAP notes

S dot O dot A dot P

Planets Subjective objective analysis plan
symbol objective

2: Objective

In the second Objective stage of the assessment, the physio makes her/his own observation and evaluation of the patient.

1: Describe the patients posture

Describe the patients posture

What is their range of motion?
(including passive and active)

4: What reproduces the pain?

Which movements are weak?

4: What reproduces the pain?

What reproduces the pain?

4: What reproduces the pain?

What intervention helped to relieve pain and improve movement?

Try to avoid:
Giving no detail or summary detail such as: "ROM exercises given"

  [The Analysis stage now follows] Analysis

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Analysis notes alert

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

SOAP notes

S dot O dot A dot P

Planets Subjective objective analysis plan
symbol analysis

3: Assess

The third Assess stage is an analytical one where the physio further evaluates of the patient.

An assessment note might address the following:

Clinically this might be shown as something like this:

 

  • Improved pain by 2/10 and mobility by 5 deg with todays treatment
  • R sided Z-joint elbow pain due to fall 6/12 ago
  • Pain increases with elbow extension, R lateral flexion and rotation. Pain eases with flexion exercises
  • Patient requires elbow stabilising exercises that progress into functional activity
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Plan 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(? )

SOAP notes

S dot O dot A dot P

Planets Subjective objective analysis plan
symbol plan

4: Plan

The fourth and final Plan stage is an evaluation of treatment to date.

Typical Plan notes might be

What is the patient’s home exercise program? Crook-lying ADIM 5 sec hold, 10x2, breathing gentle Crook-lying pain-free ROM rotation, breathing gentle

When will he/she return next? Introduce leg movements with abdominal activation


What will you re-assess at the next appointment? re-assess VAS scale

 

  1. Crook-lying ADIM 5 sec hold, 10x2, breathing gentle Crook-lying pain-free ROM rotation, breathing gentle
  2. Returns Friday at 10am
  3. Re-assess ROM and abdomen strength
  4. Introduce leg movements with abdominal activation

 

Your notes

Next appointment? (for patient)

(next appointment):

VAS scale?

 

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SOAP notes

S dot O dot A dot P notes

A walk-through guide

symbol subjectivesymbol objectivesymbol analysissymbol plan

Starting with the Patient Record Form we note down all detail, in the following way
[click any image for gallery]:

 

And remember, don't:
pass judgement on a patient e.g. "Patient is over-reacting again", and don't document irrelevant information e.g. "patient complaining about previous therapist".

 

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