Orthotic fitters course SOAP notes Accurate 100%(RATED A+)

SOAP - ANSWER• S = Subjective • O = Objective • A = Assessment • P = Plan SUBJECTIVE - ANSWER-What happened -How it happened -Patient's descriptions -Where it happened (e.g. surface, weather conditions, etc.) -When it happened -Previous history -Any unusual noises/sensations heard/felt -What treatment has been done for it -Etc. OBJECTIVE - ANSWEREverything you SEE and DO Results of limitations, instability, apprehension › General appearance (discoloration, deformity, rigidity) › Edema (swelling) › Temperature › ROM › Gait analysis › Method of transport to you › Muscle strength › Muscle tone › Posture › Endurance › Sensation › Mental alertness › Respiration › Pulse › Skin/wounds › Stress tests (reflexes, specific tests for body parts) › Functional tests ASSESSMENT - ANSWERYou will want to document your assessment of the condition you are dealing with. This would be your educated guess of what is going on. PLAN - ANSWER• Treatment the patient will receive - First aid treatment, splint, wrap, crutches, re-evaluate tomorrow a.m. • Short & Long term goals • Expected functional outcomes • Frequency per day/week • Treatment progression • Patient education - home instructions • Referral • Discharge notes The SOAP note should briefly express the following: - ANSWER• Date and purpose of the visit, patients symptoms and complaints. •The current physical evaluation, include height, weight, age. • New results of studies, reports, assessments, physicians orders. •The