Week 3 Documentation: SOAP notes and evaluations Terms in this set (27) What does "S" stand for in a SOAP note? Subjective What is written in the subjective -Clients report of limitations, concerns, problems -Summarize what the client says

Week 3 Documentation: SOAP notes and evaluations Terms in this set (27) What does "S" stand for in a SOAP note? Subjective What is written in the subjective -Clients report of limitations, concerns, problems -Summarize what the client says that is relavent to tx -Use conversation to build occupational profile -If patient is non-verbal, may need to provide information that was provided by family, caregivers or other professions -EX. Client reports that her shoulder feels better after application of kinesiotape to reduce subluxation Common errors when writing subjective -Not using communication like effectively -Not writing concise, coherent statements -do not repeat the client's medical history What does the "O" stand for in a SOAP note? Objective What is written in an objective? -begin with a statement about the length, setting, and purpose of the tx session -next, provide a brief overview of the key deficits that are affecting the client's performance -follow the opening statement with a summary of what you observed; how did the client present -be professional, concise and specific Step 1 of writing an objective The formula is: Patient participated in a _- minutes OT session in (what setting) for (intervention) for (what occupational gain - EX. Patient participated in a 30-minute OT session in an outpatient clinic for skilled instruction in joint protection and energy conservation to increase safety during ADLs tasks. Step 2 of writing an objective -paint a picture -one or two sentences to describe key deficits (PRESENTATION SENTENCE) - EX. Client seated in w/c and presents with dense hemiparesis for (L) UE and (L) LE, edema of (L) hand, and severe (L) neglect. Week 3 Documentation: SOAP notes and evaluations Step 3 of writing an objective -Interventions and client's response to interventions -chronologically -categorically -occupation -client factors -performance skills Example of an objective Client participates in an 18 minute OT session in IPR , focusing on improving grip, left side neglect, and one handed dressing strategy using a theraband. Client is sitting in w/c and dressed appropriately for therapy. Client presents with left hemiparesis and left neglect and client is aware of these deficits. Client used device to improve grasp 10x (R) side, and 3x (L) side. Client performed task of crossing midline by unclipping clothes pins with (R) hand on client shirt and then clipping onto yardstick above head and then unclipped and discarded the clips in a basket on the (L) in order to focus on (L) neglect. Client participated in one handed dressing using a therapy band 3x. Verbal cues were necessary in order to keep clients eyes open. Client fatigued from using (L) side, mostly wrist. What does the "A" stand for in a SOAP note? Assessment What is written in an assessment? -THE 3 P's -Problems- contributing factors, impact, ability to engage in occupation -Progress- what improvements have you observed? -Potential- Potential for success in rehab -Justification sentence Example of a problem sentence in an assessment Deficits in (R) UE, increased tone and decreased active movement, limit patient's ability to complete basic self-care tasks Example of a progress sentence in an assessment Patient's use of a button hook allows for independence with donning shirt. Example of a potential sentence in an assessment The client's ability to follow verbal cues indicates good potential to improve functional transfer status. Example of a justification sentence in an assessment Client would benefit from skilled OT services to improve functional mobility in order to complete ADLs T/F the "A" should support information in "S" and "O" and NO new information should be introduced TRUE Full example of assessment section of a SOAP note Client's increased pain and poor functional use of the (R)UE result in the client requiring mod (A) to don and button shirt. Ability to place the (R) UE in the shirt indicates progress from max assist to mod assist. Recent progress is a good indicator that patient will be (I) in upper body dressing. Pt. would benefit from skilled OT services for instruction in one handed dressing techniques and (L) hand fine motor training to improve the use of the (L) hand as the dominant hand for UE dressing What does the "P" stand for in the SOAP note? Plan What is written in the plan? -frequency -duration Week 3 Documentation: SOAP notes and evaluations Common errors when writing the plan - failing to provide the anticipated duration of OT services - using the phrase "plan to assess". It is implied that assessment is ongoing, but formal assessment has already occurred on the initial evaluation -listing interventions that are not relevant to the client's current setting Example of a plan Continue to treat pt. for 30 min. sessions BID for 2 more weeks for skilled ADL training to improve one-handed dressing and to introduce fine motor training for (L) non-dominant hand. Referral will be made to local agency for assistance with obtaining adaptive equipment due to pt.'s limited financial resources. Why is the plan important? -provides direction for the next session -provides information if a different therapist is treating the patient -provides communication to OTA - allows coverage if you are absent and another therapist covers your client What are the different adult settings where therapists can conduct an evaluation? -acute -inpatient rehab -outpatient rehab -home health -skilled nursing facility (SNF) What is included in an evaluation? -referral information -occupational profile -assessments used and the results -analysis of occupational performance -performance -interpretation/summary -recommendation/frequency -goals SOAP format in an evaluation S- pain, what the patient said O- assessments, measurement, occupational performance A- summary, problems, potential, justification P- STGs, LTGs, frequency and duration Re-evaluation -each venue is different - insurance coverage depends on need for re-evaluation in acute and inpatient - re-administer assessments -create a new POC or discharge SOAP note format for re-evaluation S- what the client said O- assessment, measurements, chart for comparison A- 3-P's, justification, address goals met or not, make new goals P- make recommendations for further treatment