SOAP note writing is an essential part of the physical therapist's job. This type of written assessment is an integral part of contributing to the overall health condition of the patient and her recuperation. The acronym SOAP stands for: Subjective, Objective, Assessment and Planning. These are the basis for the notes regarding the physical therapist's patient. When a patient receives physiotherapy, other medical personnel involved in the patient's care will read these notes and understand the medical issues from the viewpoint of the physical therapist and tailor their recommendations accordingly.
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Interview the patient and note their words when they are telling you about how they feel. This is the subjective part of the medical notes and should be in the form of a direct quote, such as "I am having less pain today" or "I can move my arm a little further out than I could last week." This quote should be written exactly as the patient states it without any grammatical correction and in quotation marks.
Survey the patient's blood pressure, pulse, respiration rate, temperature and range-of-motion abilities. Laboratory or radiology reports are also recorded in this section of the note. This is the objective part of the SOAP note and is based purely on those factors as well as your palpating the injured area, assessing the patient's range-of-motion and the overall physical examination.
Assess your findings of the patient's condition based on the subjective and objective findings and record this in the assessment portion of the note. Other things to document would be how the patient tolerated any portion of the physiotherapy treatment. This would include statements, such as "the patient tolerated range of motion without difficulty," for "radiographs of the patient's injured area are WNL (within normal limits)," both common phrases in this part of the note.
Plan the course of treatment you will implement regarding the patient's future rehabilitation in the final section of the SOAP note. The planning section of the note involves determining the direction that you will take with the patient. Common phrases in this section often read, "Continue the current treatment plan", "Increase range of motion exercises to three times daily" or "No further treatment required. Follow up in two months."
Subjective, Objective, Assessment and Planning
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