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Injury Evaluation

Injury Evaluation. The S.O.A.P. Note Documenting Injuries. Bell Work. Think back to a specific day on a family vacation when you were little. What do you remember? What people where present? What did you do? What was the highlight of the day?

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Injury Evaluation

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  1. Injury Evaluation The S.O.A.P. Note Documenting Injuries

  2. Bell Work • Think back to a specific day on a family vacation when you were little. • What do you remember? • What people where present? • What did you do? • What was the highlight of the day? • Do you think you would remember more if you had a journal entry of the day?

  3. Think-Pair-Share • With a partner, share your experience. • What would the advantages be if you wrote down what you did, and mentioned more of the specifics?

  4. Bell Work • Grab your binder, supply boxes, and white boards from the cabinet • Grab your worksheets from the front table • Discuss in your group 3 reasons it is important to write down information gathered during the evaluation (HOPS) process. Write them down on your white boards

  5. Objectives • Identify SOAP • Identify where information goes into SOAP • Identify the importance of documentation of the evaluation (HOPS) process • Provide a report on the findings of an injury evaluation

  6. SOAP Note The SOAP note format provides a standard format for recording injury information S – Subjective O – Objective A – Assessment P – Plan

  7. SOAP Note vs. HOPS • What was the purpose of HOPS? • A system of injury evaluation • How does it differ from a SOAP note?

  8. Terminology • S= Subjective Findings • Record any findings that the athlete, coach, teammate or parents says about how the injury was sustained. • History (Hx) • Have you had this type of injury before? • Mechanism of injury • How did it happen? • Symptoms • What do you feel?

  9. Terminology • O=Objective Findings • Record anything that was observed or measured during the evaluation • Observations • Swelling? Deformity? Limping? • Palpations • Crepitus? Deformity? • Special Testing • Laxity? Decreased ROM?

  10. Terminology • A=Assessment • What the evaluator’s opinion or diagnosis is of the injury • Grade 2 sprain of R ATF ligament • Always include the degree of injury, along with noted side • Incorrect: Sprained ankle

  11. Terminology • P=Plan • First aid treatment • AT’s disposition to injury (ie referral, f/u next day) • Recording of short term and long term goals for the injury • Short Term: Rest, Ice, begin ROM exercises • Long Term: Progress from bike to ellipical to treadmill over the next 4 weeks.

  12. Why use a SOAP Note?

  13. Documentation • You cannot remember every detail. • SOAP notes provide an organized way to keep good records of an athlete. • It is a good way to record an individual’s progress over time. • It can be used as evidence to protect you in case of a lawsuit.

  14. Now what? • You filled out a SOAP note document for an injured athlete. • Do you stop at the day of injury? • SOAP notes are used throughout the entire recovery process until the athlete has been cleared or has resumed full activity.

  15. Progress Notes • Routinely written after each progress evaluation done throughout the course of the rehab program • Info should concentrate on type of tx and patient’s response to tx • Progress made towards short/long term goals • Changes in previous tx plan and new course of tx over the next several days

  16. Gradual swelling Tingling pain Ice for 15 min. Begin ROM rehab Right ankle sprain Limping Tender to touch Concussion “Giving out” feeling Objective Subjective Plan Plan Assessment Objective Subjective & Objective Assessment Subjective Where does it go?Determine if it is Subjective, Objective, Assessment or Plan.

  17. Where does it go?Determine if it is Subjective, Objective, Assessment or Plan. • Holding elbow • Grade III R. ACL Sprain • Felt/heard ‘pop’ • CWP 20’ • ROM exercises for ankle • Discoloration • PEARL • Sharp, shooting pain • Objective • Assessment • Subjective • Plan • Plan • Objective • Objective • Subjective

  18. Where does it go?Determine if it is Subjective, Objective, Assessment or Plan. • Varus Stress Test • P/T on fibular head • Decreased strength • Throbbing pain • Patellar Tendonitis • Ice bag 15’ • Progress from walking to running in 2 weeks • Objective • Objective • Objective • Subjective • Assessment • Plan • Plan

  19. SOAP Note • Read through the worksheet and record your findings on the SOAP note

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