Chapter 07: SIMPLE SOAP – NOTE EXAMPLES

Simple Soap – Note Examples

So far we have taken a look at the various pieces of a SOAP-note.   Before we discuss how to construct them individually, let’s look at how they fit into the big picture of a completed SOAP note.  The following are simple SOAP notes to give us a frame to view the SOAP note through.

There are 4 Examples to review (click the example to navigate to it quickly):

• Example 1
• Example 2
• Example 3
• Example 4
• YOUR TURN ACTIVITY

Example 1

Let’s look at the following simple SOAP note example.

S:      Patient states that he did not sleep well last night due to phantom limb pain, RLE; he hopes to take his prosthesis home with him soon so he can use it to walk around the house “like a normal person”.

O:     Gait training: With AK prosthesis in parallel bars, 30′ x 2, with mod A.  Transfers: Sit to / from stand from w/c: min assist with verbal cues for hand placement.  Patient flexes trunk forward and laterally to R during R LE weight bearing on the prosthesis.   Therapeutic Exercise: Mat exercise program: glut sets, SLR, side-lying hip adduction and abduction; 3 sets of 12 reps each bilaterally. Manual stretching of R hip flexor with patient in L side-lying, 3 x 30 second hold. Right hip flexion contracture of 20 degrees (measured in supine).

A:     Right gluteus medius weakness and hip flexion contracture causing patient to lateral trunk flex to R. Patient not ready to take prosthesis home until he can ambulate with walker with only supervision assistance. Presently he is a fall risk if he were to ambulate at home with prosthesis.

P:  Continue gait training activities; concentrate therapeutic exercises on gluteus medius strengthening and hip extension ROM as per PT POC.

Your Name along with SPTA / Your CI’s name.  (Or whatever signature format your clinic uses).

Example 2

S:      Patient notes decreased cervical pain after last treatment; now able to rotate her neck to the left to look for traffic while driving. No pain medications required today.

O:     US: 100% 1.2w/cm2, 1Mhz x 5′ to R UT, rhomboids, LS mm in sitting. STM, TPR to R UT, rhomboids, LS mm in sitting. Therapeutic exercise per flowsheet.

A:    Patient with improving c-spine ROM and decreased pain. Compliance with HEP is excellent is allowing her to recover without use of pain medications.

P:      Continue 2x/weekly per PT POC.

Example 3

S:    Patient reports 0 – 3/10 right knee pain; increasing up to a 5/10 only when he twists the knee during ambulation.

O:     Therapeutic exercise per flowsheet. Modalities:  NMES right quads, 50pps, 10 sec on/off x 10 mins w/ QS with patient in long sitting. Cold pack to right knee post NMES.    Education:  HEP Instruction: Reviewed present activities, as per flow sheet, with patient completing all activities without pain:  2 sets of 8 reps. Verbal cues needed for SLR technique only.  Upgrades these activities to 3 sets of 10 – 12.  After training, added standing lunges and wall slides (2 sets of 8) to HEP.  Strength: MMT knee extension: Left: 5/5; Right 4/5.   Gait training on level surfaces (with SPC) to reduce effects of circumduction on right. Integrated use of mirror for visual feedback as well as the use of a foot ladder (20′).  Patient requires 25% verbal cues to make corrections during these activities.

A:    Patient’s pain is steadily reducing despite intermittent exacerbations during twisting movements.  Gains noted in strength and tolerance for exercise. Patient’s circumducting gait does cause a twisting moment at the knee which increases his discomfort. As noted, this deviation is improving through various PT interventions. It is reasonable to expect that a continued improvement with this deviation, through gait training and strengthening activities, should allow the patient to return to his premorbid pain free state of ambulation without AD.

P:    Continue 3x/weekly progressing therapeutic exercise and gait activities per POC.

Example 4: What’s missing?

So now you have seen a few examples of SOAP notes.  All very generic and primarily focused for an outpatient clinic.  Let’s look over this example to see what is missing.

S:     Patient reports they had some pain last night, but not much pain now.

O:     Transfers: W/C to mat. Patient loses balance to left sometimes.

Therapeutic exercise: Seated balance activities.  Knee extension and hip flexion.

Gait Training: RW length of PT gym twice.

A:    Patient progressing with exercises.

P:  Continue BID per POC plan.

YOUR TURN ACTIVITY

Let’s see if you can identify the section of the note for each entry: S, O, A or P.