Contrasting Physiological Responses in Different Age Groups for Healthcare Documentation

1. Standard 11Rehab Careers S.O.A.P. Notes

2. Standard 11 Compare and contrast physiological responses of patients of differing ages, current health status, and presence of acute and/or chronic diseases. For example, compare the response of a healthy elderly patient with a fractured femur to an overweight adolescent with the same fracture. Explain how one would differentiate treatment to meet varying conditions.

3. SOAP Notes • A format/style of documentation in healthcare • Any document can be written in this style • Originally designed for Osteopathic medicine • Designed to achieve a more structured evaluation • Includes a thorough hx (history) & physical exam • Allowed for more accurate Dx (diagnosis) • Organized, concise document • Utilizes medical abbreviations

4. Purpose of SOAP Notes Liability: legal document Communication: method to communicate w/ other healthcare professionals and/or your staff Insurance: third party reimbursement Progress Report: review report to decide if Tx (treatment) is effective Research: to collect injury data statistics Education: to improve quality of care

5. SOAP Notes • Write it as soon as possible before it fades from your memory • May have to take notes during the evaluation initially • Notes should organized & chronological • Use subheadings • Underline headings • Notes should include past & present examinations, tests, Tx, & outcomes

6. SOAP Notes • Notes must be legible! • Never use “I” refer to your professional title • i.e. ATC, PT, OT, RN • Use quotes whenever possible • Do not use hyphens • Confused w/ minus signs • Use black or blue ink only • Sign all evals and progress notes

7. What does SOAP stand for? • S = Subjective • O = Objective • A = Assessment • P = Plan

8. Subjective • Information obtained from Pt (patient) • Very important to get a good Hx. The background of the injury will often give you the answer • Includes: • Hx: pertinent background information • MOI (mechanism of injury): how, what, when, where of the injury • C/O (complains of): Pt’s sx (symptoms) including description of pain • Meds: current medications being taken (Rx, OTC, sup) • All: any allergies

9. Physiological Responses

10. Subjective • Hx: • PSHx (past surgical history), PFHx (past family history), Past Tx, social hx, prev injuries, change in activity, • MOI: • Any unusual noises/sensations heard/felt • Onset of injury: acute or gradual (chronic) • C/O: (or chief complaints - CC) • Pain scale (1-10) • Location, severity, & type of pain • Burning, stinging, sharp, dull, deep, nagging, radiating, constant, @ night, in a.m. • Pain worse during or after activity • Limitations from pain • What aggravates & alleviates pain • Meds: • All:

11. Possible Questions: • How did this injury occur? • Where do you feel pain? • When did the injury occur/ When did it start hurting? • Are you having trouble walking/writing/ getting dressed/etc.? • Have you injured this area before? • Did you hear or feel anything pop or tear?

12. Unusual sounds/sensations • Clicking/Locking: • Meniscus/labralinjury • Pop: • Ligament injury • Patellar/GH dislocation • Muscle tear • Snapping/Popping: • Tendonitis • Bursitis • Pulling: • Muscle strain

13. Objective • Physical findings: • Everything you observe, palpate, or test • Typically measurable/repeatable • Includes: • Observation • Inspection • Special Tests • Neurovascular • ROM (range of motion) • MMT (manual muscle testing)

14. Objective • Begins the moment you first see them • Assess the individual’s state of consciousness & body language • May indicate pain, disability, fracture, dislocation, or other conditions • Note their general posture, willingness & ability to move • When you start your exam: • Check bilaterally & think outside the box! • Don’t get caught up in the specific area

15. Observation ALWAYS compare bilaterally Gait & posture Obvious deformity Bleeding Mental alertness – state of consciousness Discoloration/Ecchymosis Swelling Atrophy/Hypertrophy Symmetry Scars Skin

16. Objective • Palpation: • Deformity • Point tenderness • Temperature • Crepitus • Special Tests: (+/-) • Fx (fracture) tests • Specific tests for body part • Functional tests

17. Fracture Tests • Squeeze/Compression • Tap • Ultrasound • Tuning Fork *Positive Sign: Localized, Shooting Pain

18. Objective • (NV) Neurovascular: • Myotomes - Strength • Dermatomes - Sensory • Skin Temp/Color • Cap refill • Pulse/BP • Reflexes (superficial & deep tendon) • ROM: (in degrees) • AROM/PROM (active ROM/passive ROM) • End feel • MMT/RROM: (resistive ROM) • Strength tests (0-5 scale) • Break tests (0-5 scale)

19. MMT Scale • 0/5: no contraction • 1/5: muscle flicker, but no movement • 2/5: movement possible, but not against gravity • 3/5: movement possible against gravity, but not against resistance by the examiner • 4/5: movement possible against some resistance by the examiner • Can be subdivided further into 4–/5, 4/5, and 4+/5 • 5/5: normal strength

20. Assessment • Your professional opinion of the type of injury/illness • Based off the subjective & objective portions of the exam • Include: • Anatomical location • Severity • Description • The exact injury/illness may not be known • Exp: Possible 2° L ATFL sprain

21. Plan • Tx the patient will receive that day • Ice, splint, crutches • Plan for further assessment or reassessment • Patient/Family education: Home instructions • i.e.: Concussion Take Home Instructions • Referral • Short & Long term goals: need to be measurable • Expected functional outcomes • Equipment needs • Plans for discharge/RTP (return to play/participation)

22. Plan – Treatment/Therapy • Frequency • Location • Duration • Type • Progression • Example of generic plan: • Pt will be seen TIW (3x a week) x 6 weeks to include TE (therapeutic exercises) & modalities as needed

23. Plan - Short-term Goals • Goals that will allow Pt to achieve long-term goals • Record specific rehab ex’s • Record any modalities used & exact parameters used • Day to day or weeks • Example: • Increase R shoulder flexion to 145o (from 125o), increase function so Pt can comb their hair c R hand in 7 days. • List specific stretching & functional exercises

24. Plan - Long-term Goals • Expected outcomes • Includes: • What is the outcome • What will it take to achieve that outcome • Include measurements and specific interventions for each goal • What conditions must exist for a good outcome • Example: • Return to full strength (5/5 from 4/5), full ROM (170o from 145o), return to volleyball • List specific strength ex’s, stretches, & sport specific activities

25. Progress Note • Written after each eval/rehab session • Can be performed as SOAP note or as a summary • Include response to Tx & type of Tx • Progress made towards short-term goals • Changes in Tx or goals • Important notes: • Seen by physician • Results of diagnostic tests • RTP status

26. Progress Note - Subjective • Response to treatment & rehab • Decreased/increased pain • Include why: from rehab, standing all day, etc • Overall psychological profile (i.e. bored) • Reassessing subjective information from previous notes • Change in function • Change in pain (location, type) • Patient compliance issues c ex’s

27. Progress Note - Objective • Tx provided • Reassess & compare measures that may have changed • Note changes in ROM, strength, functional ability • Indicate any changes or special notes for rehab • Change in modality parameters • Assistance needed/not needed during exercises • Added/decreased weight/reps/sets/frequency • Added or changed exercises

28. HIPS/HOPS • History • Observation/Inspection • Palpation • Special Tests