Introduction To SOAP Notes 2024 Updated Exam

Introduction To SOAP Notes 2024 Updated Exam What does SOAP stand for? - ANSWER S=Subjective (something patient tells you) O=Objective (something clinician does to patient) A=Assessment (Putting info together, and figure out what it means) P=Plan (how to get the patient to their highest lvl of function) What are some examples of subjective information? - ANSWER Things the patient, family, caregiver, etc. tell us about their: -Chief complaint -functional status -living environment -family health history. -etc... Important things to do during the subjective phase. - ANSWER Be consise. Quote the patient verbatim. To illustrate confusion/memory loss, eliminate discrepancy... Examples of things found during the objective phase. - ANSWER Things the PT finds: -system review -test and measures -functional skills -medical history (from medical record not patient) Describe the assessment phase. - ANSWER Your professional opinion: PT diagnosis: -specific practice pattern(