Chapter 03: The COMPONENTS: The ‘What’ of a SOAP Note

Time to get back to the SOAP note and discuss ‘what’ each part of the note refers to. As a review:

S =      Subjective

O =     Objective

A =      Assessment

P =      Plan

 

Let’s take a big-picture look at each section first.  Later, we will dig deeper with each area and practice creating our own SOAP note sections (S, O, A, P) as well as SOAP notes.  But first….

 

The “S”:  The SUBJECTIVE section.

The SUBJECTIVE section of the note includes information that is told to you. This includes information the patient reports to you verbally (for example, their SYMPTOMS) or information their family shares with you. Other examples of subjective content include:
  • How they are feeling (including their level of pain, level of fatigue, general sense of well-being or illness, etc.)
  • How they are responding to their PT treatment (since the PT sessions began or since last treatment…)
  • How their PT is impacting their functional ability and quality of life (what is improving outside of the therapy and what is not)
  • What is occurring in their life that may be relevant to their PT care (This may include job or family matters, comorbidities or other medical tests)
In situations when the patient cannot talk, a statement of the patient’s general appearance or mental status can be used. To be clear, SUBJECTIVE information is includes what is said and not what you think they might be feeling. It is usually gathered at the beginning of your session. You may use quotations if you write down EXACTLY what the patient said….but we get to that, along with many other aspects of writing a SUBJECTIVE entry in a subsequent section.

The “O”: The OBJECTIVE section:

The OBJECTIVE section includes information that is reproducible and readily demonstrable; information that is gathered using data – collecting methods such as measurements, test, and observations. If the subjective section included the patient’s “feelings”, the OBJECTIVE section records the patient – care “facts”. Another way to think of this is in terms of ‘signs and symptoms’: If the symptoms are reported in the subjective section, the signs are found in the objective section.

 

A few examples of data included in the objective section:
  • The intensity, duration, location and settings of various modalities.
  • The distance, device, weight bearing status, deviations, compensations and level of assistance for gait (or transfer) training.
  • Goniometric measurements or MMTs results.
  • Vital signs
  • Therapeutic exercise parameters and positions.
  • We will learn more on developing an OBJECTIVE entry in a subsequent section.
FLOW SHEETS:

 
 

Sometimes the objective data related to a patient’s exercise plan is kept in a separate location in the PT gym and is recorded on a paper log referred to as a Flow Sheet.
  • Flow sheets are used to record the patient’s therapeutic exercises or maybe modality use.
  • The flow sheet is not a substitute for the SOAP note, but rather it is a separate (hard copy / paper form) supplement the actual note.
  • Typically, the PT or PTA will document note not only the reps, sets and position of the patient on the flow sheet, but if the patient needed any assistance (and what type) as well.
  • This form of documentation may also have an area to write a narrative
  • You will need to be sure where you will be signing your entries on these forms — always check with your CI or PT.

The “A” Section: The ASSESSMENT

The ASSESSMENT section is where we provide an interpretation, analysis and our professional judgment of the patient’s overall performance and response to PT. This is the most challenging part of the note for all of us; student to experienced clinician. To justify care, we need to explain why the selected interventions were used and how they are (or not) helping the patient achieve their goals.  In class, we will be discussing something called “Defensible Documentation”.  For now, let’s just say that Defensible Documentation refers to the notion that our documentation should be presented in a way as to explain the rationale for all of our treatment interventions and our responses to our patient’s ever-changing status.  We use the Assessment section to offer that rationale.

Given the importance of the assessment section, we will be spend much more time on its development in a subsequent chapter. For now, appreciate that this is where we:

  1. Include statements about the patient’s overall progress o(or lack of progress) towards their goals
  2. Summarize and relate the patient’s statements (from the subjective section) to the patient’s overall progress, your interventions and the plan for future PT sessions.
  3. Describe how the objective data (specially your interventions) were related to the patient’s overall goals and subjective comments and therefore essential to the patient’s recovery.

The “P”: The Plan       

The PLAN refers to what is next for our patient. Often, our plan is to “Continue with the current PT POC”. However, some clinics may want you to include the frequency of visits, the specific treatment to be performed and clearly identify if there will be any changes made during the next visit. For example, we might add that the patient is to have a PT re-evaluation during the next session or that they have an upcoming MD appointment. As with each of the above sections, we will be digger deeper shortly.

 

REFLECTION ACTIVITY 2: DOC Ex 02:

  1. What other words, terms or phrases come to your mind when you think about the word ‘assessment’?
  2. Why do you think the assessment section is considered to be the most challenging area of the note to write?
  3. Aside from classroom experiences, can you name a few activities that include an ‘assessment’ – even if it is not called ‘assessment’?

 

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This work (An Introduction to Medical Documentation for the Physical Therapist Assistant by jmm49 and Dan Dandy PT, DPT, ACCE) is free of known copyright restrictions.

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