more detail

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?

SOAP notes

Planets Subjective objective analysis plan

S dot O dot A dot P notes

A walk-through guide to making SOAP notes

This walk-through simply illustrates a few typical considerations that a physio might cover.

symbol subjective

1: Subjective

The first stage is always the Subjective in which the physio listens to the patient (the subject) and notes as much detail as possible. A patient's reply typically will include these details:

Where is the pain

1: Where is the pain? 2: what type of pain? 3: how long has it been there? 4: how did it start?

1: (where is the pain?) "top of the pelvis"

2: (what type of pain?) "dull, constant pain, with stiffness and it moves around the right hip area"

3: (How long has it been there?) "six months"

4: (How did it start?) "it started after a fall"

 

Notes

  Based on the above answers, the following notes are now possible to complete:

Name of your patient:

(patient name):

What did your patient say?

(my patient said):

What is their VAS scale:

  [The assessment of the patient now follows at this stage]

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See notes alert

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

Subjective objective analysis plan
symbol objective

2: Objective

The second Objective stage of the assessment addresses the physio's own 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?

 

Your own notes

What did you notice? (diagnosis)

(I arrived at this diagnosis):

Which home exercises? (if given)

(present exercises):

 

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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

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:

How do you think this patient is benefiting from physio treatment?

What do you think is happening to cause this pain?


Why? Improved pain by 2/10 and mobility by 5 deg with today's treatment

What needs to be done to recover? R sided Z-joint lumbar pain due to fall 6/12 ago

What intervention helped to relieve pain and improve movement? Pain increases with lumbar extension, R lateral flexion and rotation. Pain eases with flexion exercises

What intervention helped to relieve pain and improve movement? Patient requires lumbar stabilising exercises that progress into functional activity

Clinically this might be shown as something like this:

 

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

 

Your own assessment notes

What is happening? (likely cause)

(this seems to be the cause):

What treatment do you plan? (likely treatment)

(treatment planned):

 

S
O
A
P
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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

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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