際際滷

際際滷Share a Scribd company logo

SOAP Note for Physiotherapy Assessment .pdf

Sejal Sailor
Sejal Sailor

SOAP note for physiotherapy assessment

1 of 4
Downloaded 19 times
SOAP Note for Physiotherapy Assessment A thorough assessment of the patient requires to carry out different physical tests to know about the patients ability and disability. The purpose of the assessment should be to fully and clearly understand the patient's problems, from the patient's perspective as well as the clinician's, and the physical basis for the symptoms that have caused the patient to complain. One of the most common assessment recording method used is the problem-oriented medical record methods, which is known as SOAP" notes SOAP stands for the four parts of the assessment: o Subjective o Objective o Assessment o Plan This format was introduced by Dr. Lawrence weed for a medical record called ProblemOriented Medical Record (POMR). The use of SOAP notes helps the physical therapist to organize and plan quality patient care. This method is especially useful in helping the examiner to solve a problem. The subjective session of the SOAP notes is about what the patient is experiencing. Subjective Assessment includes, o CHIEF COMPLAIN o HISTORY OF PRESENT ILLNESS o HISTORY OF PAST AND FAMILY ILLNESS o REVIEWS OF SYMPTOMS o CURRENT MEDICATION / OTHER TREATMENT o ASSOCIATED OTHER DISEASES / ALLERGIES
SOAP Note for Physiotherapy Assessment The objective part refers to data that the physical therapist collects and measure from the patient. They are measurable and observable information by the physical therapist. o It includes, 則 Vital signs 則 Examination of pain 則 Physical examination 則 Laboratory data/ images result 則 Other diagnosis data 則 Reviews of documentation of other clinicians Observation Part includes, Observation of o Posture o Gait o Deformity o Swelling/oedema o Skin discolouration o External appliance Palpation Part includes palpation of o Tenderness o Scar o Spasm Examination of movement includes o Movement active and Passive ROM
SOAP Note for Physiotherapy Assessment o Muscle Strength o Girth measurement o Limb length measurement o Functional assessment. o Special tests o Reflexes and cutaneous distribution o Joint play movements Diagnostic imaging (X-ray, MRI, CT scan, Ultrasonography etc.) After subjective and objective data collected, The physical therapist interprets and identifies factors that are not within the normal limit for people of the same age under the assessment part of SOAP notes. Assessment at the last written as, o Problem List. o Long term Goals o Short term goals... o Summary... The plan in the SOAP note is the final step in the planning procedure for patients care. The plan includes setting the goals for treatment and to frame the treatment protocol of the patient. The following information should be included in the plan. o Location of treatment i.e. at the department, at the bedside, at home. o Frequency per day or per week the patient will be seen o Detailed treatment protocol patient will receive.
SOAP Note for Physiotherapy Assessment o Treatment Progression o Discharge notes with the home program plan o Patient and family education i.e. Home program plan explained to patient or relatives o Referrals to other services i.e. to the orthopaedic surgeon or need for X-ray References : Magee DJ. Orthopaedic physical assessment-E-Book. Elsevier Health Sciences; 2014 Mar 25. Kettenbach G. Writing Soap Notes: with Patients/Clients Management. Dec. 2003.

More Related Content

SOAP Note for Physiotherapy Assessment .pdf

  • 1. SOAP Note for Physiotherapy Assessment A thorough assessment of the patient requires to carry out different physical tests to know about the patients ability and disability. The purpose of the assessment should be to fully and clearly understand the patient's problems, from the patient's perspective as well as the clinician's, and the physical basis for the symptoms that have caused the patient to complain. One of the most common assessment recording method used is the problem-oriented medical record methods, which is known as SOAP" notes SOAP stands for the four parts of the assessment: o Subjective o Objective o Assessment o Plan This format was introduced by Dr. Lawrence weed for a medical record called ProblemOriented Medical Record (POMR). The use of SOAP notes helps the physical therapist to organize and plan quality patient care. This method is especially useful in helping the examiner to solve a problem. The subjective session of the SOAP notes is about what the patient is experiencing. Subjective Assessment includes, o CHIEF COMPLAIN o HISTORY OF PRESENT ILLNESS o HISTORY OF PAST AND FAMILY ILLNESS o REVIEWS OF SYMPTOMS o CURRENT MEDICATION / OTHER TREATMENT o ASSOCIATED OTHER DISEASES / ALLERGIES
  • 2. SOAP Note for Physiotherapy Assessment The objective part refers to data that the physical therapist collects and measure from the patient. They are measurable and observable information by the physical therapist. o It includes, 則 Vital signs 則 Examination of pain 則 Physical examination 則 Laboratory data/ images result 則 Other diagnosis data 則 Reviews of documentation of other clinicians Observation Part includes, Observation of o Posture o Gait o Deformity o Swelling/oedema o Skin discolouration o External appliance Palpation Part includes palpation of o Tenderness o Scar o Spasm Examination of movement includes o Movement active and Passive ROM
  • 3. SOAP Note for Physiotherapy Assessment o Muscle Strength o Girth measurement o Limb length measurement o Functional assessment. o Special tests o Reflexes and cutaneous distribution o Joint play movements Diagnostic imaging (X-ray, MRI, CT scan, Ultrasonography etc.) After subjective and objective data collected, The physical therapist interprets and identifies factors that are not within the normal limit for people of the same age under the assessment part of SOAP notes. Assessment at the last written as, o Problem List. o Long term Goals o Short term goals... o Summary... The plan in the SOAP note is the final step in the planning procedure for patients care. The plan includes setting the goals for treatment and to frame the treatment protocol of the patient. The following information should be included in the plan. o Location of treatment i.e. at the department, at the bedside, at home. o Frequency per day or per week the patient will be seen o Detailed treatment protocol patient will receive.
  • 4. SOAP Note for Physiotherapy Assessment o Treatment Progression o Discharge notes with the home program plan o Patient and family education i.e. Home program plan explained to patient or relatives o Referrals to other services i.e. to the orthopaedic surgeon or need for X-ray References : Magee DJ. Orthopaedic physical assessment-E-Book. Elsevier Health Sciences; 2014 Mar 25. Kettenbach G. Writing Soap Notes: with Patients/Clients Management. Dec. 2003.