SOAP Notes

1. SOAP Notes Chase Paulson, MS, ATC

2. What is a SOAP Note? • SOAP is an acronym for the areas of documentation during an injury/illness • S: Subjective • O: Objective • A: Assessment • P: Plan Ray, 2005

3. Why do we write SOAP Notes? • To provide a concise record of the patient’s progress from time of injury until return to play • To organize information surrounding a physically active patient’s specific complaints • To ensure the correct information is communicated between health professionals

4. When do we write SOAP Note? • SOAP Noting is done before, during, and/or after each treatment session • It is an ongoing process done during the entire treatment period

5. What is included in a SOAP Note? • Patient’s Name, sport, ID# • Body part injured • Date of injury/surgery • Four areas of the SOAP Note • ATC Signature

6. S: Subjective • Subjective evaluation of the patient’s problem • This is what the patient tells you, or what you have learned from the patient • Symptoms & their behavior • History • Past history • Written word-for-wordwhat they say

7. O: Objective • Objective evaluation of the patient’s problem • Physical data observed by the athletic trainer during evaluation • Observation, palpation, ROM, special tests • Other testing results (x-ray, MRI)

8. A: Assessment • Assessment of the patient’s problem/progress • The athletic trainer’s impression/judgment of the problem/progress • Based on the subjective/objective data • Diagnosis / progress

9. P: Plan • Plan of action that the athletic trainer will take to resolve the problem • Goals: immediate, short-term, long-term • Referrals • Rehabilitation

10. Example #1 Steve was at basketball practice when he injured his right ankle. While driving to the basket he said he felt a pop on the outside of his foot. Steve stated that his pain was a 6/10. Steve came to you with moderate edema and ecchymosis over the lateral aspect of his ankle. His range of motion was limited, and he tested positive for the anterior drawer. You believe he has a grade one ATF sprain. Your goal is to RICE Steve’s ankle today and begin rehab in two to three days to strengthen the joint.

11. Example #2 Erica is coming in today to finish her gradual return to play protocol from suffering her first concussion. She reports that her previous syptoms are now gone and that everything felt normal. Yesterday’s exercise session gave her no real difficulty, and she felt no new symptoms. Her CSI & BESS test reports came back normal, and you decide she is ready to be cleared to return to practice today.

12. Example #3 John came in today to continue treatment he was receiving from his grade 2 pec major strain. Today he said his pain was a 4/10, and he could still feel a sharp pain when he tried to lift his arm. He brought his doctor report with him that stated “John was to be removed from practice for four more weeks to allow healing.” You observed edema and ecchymosis over his right chest, and noted that he still had a decrease in range of motion in abduction, adduction, flexion, and extension of the shoulder. You want to treat John today with e-stim and ice and begin a light rehab tomorrow to increase range of motion and decrease pain.