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SOAP/HOPS notes

SOAP/HOPS notes. HOPS. H-HISTORY Based on subjective findings How, when, happen before? O-OBSERVATION Based on objective findings Compared uninvolved side, swelling, deformity, discoloration, scars P-PALPATION Point to where it hurts, deformity, spasms STRESS TESTS AROM, PROM, MMTS.

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SOAP/HOPS notes

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  1. SOAP/HOPS notes

  2. HOPS • H-HISTORY • Based on subjective findings • How, when, happen before? • O-OBSERVATION • Based on objective findings • Compared uninvolved side, swelling, deformity, discoloration, scars • P-PALPATION • Point to where it hurts, deformity, spasms • STRESS TESTS • AROM, PROM, MMTS

  3. SOAP NOTES • A clean systematic way of documenting the assessment findings and recording an athlete’s progress through a rehab program • S-Subjective: who, what, when, how? • What the athlete tells you • O-Objective: ATCs findings; palpation, special tests • A-Assessment: ATC will state type and severity of injury, list problems-lack of motion, pain, functional movements • P-Plan: What ATC is going to do: referral, treated, or monitored • Rehab

  4. SOAP notes • SOAP is an acronym for Subjective, Objective, Assessment, Plan • Developed from problem-oriented style in an attempt to standardize note-taking • Subjective is info gathered from the patient • Complaints, hearsay, and impressions of the patient by the note-writer • May include the following:

  5. SOAP Notes • relevant medical history • how the patient describes the mechanism of the injury or illness • if the patient heard any noises at the time of the injury • if the patient reports a loss of function • descriptive terms of any pain or sensations associated with the injury or illness • Objective is information obtained from evaluations and tests that are reproducible by others

  6. SOAP Notes • Used to confirm things from the subjective section • Includes vital signs, range of motion testing, strength, reflexes, measures of edema, ligamentous tests, pain on palpation, gait and posture evaluation, and functional evaluation • Largest section of the note • Assessment is the writer’s professional opinion of the problems to be dealt with

  7. SOAP Notes • Includes both short-term and long-term goals • In follow-up evaluation this section is used to chart progress toward achieving the goals • Justification of any unusual goals or treatments is entered here • Plan is based on the goals • This is where the number of treatments is proposed as well as the methods used in the treatments

  8. SOAP Notes • Advantages to SOAP is the information is logically presented, it doesn’t rely on grammatical correctness, and it can be completed quickly • Disadvantage includes having to understand a particular profession before you can understand what that profession is trying to do in a situation

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