SOAP Notes

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SOAP Notes

• Chase Paulson, MS, ATC

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What is a SOAP Note?

• SOAP is an acronym for the areas of documentation
  during an injury/illness
• S Subjective
• O Objective
• A Assessment
• P Plan

Ray, 2005
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Why do we write SOAP Notes?

• To provide a concise record of the patients
  progress from time of injury until return to play
• To organize information surrounding a physically
  active patients specific complaints
• To ensure the correct information is communicated
  between health professionals

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When do we write SOAP Note?

• SOAP Noting is done before, during, and/or after
  each treatment session
• It is an ongoing process done during the entire
  treatment period

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What is included in a SOAP Note?

• Patients Name, sport, ID
• Body part injured
• Date of injury/surgery
• Four areas of the SOAP Note
• ATC Signature

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S Subjective

• Subjective evaluation of the patients problem
• This is what the patient tells you, or what you
  have learned from the patient
• Symptoms their behavior
• History
• Past history
• Written word-for-wordwhat they say

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O Objective

• Objective evaluation of the patients problem
• Physical data observed by the athletic trainer
  during evaluation
• Observation, palpation, ROM, special tests
• Other testing results (x-ray, MRI)

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A Assessment

• Assessment of the patients problem/progress
• The athletic trainers impression/judgment of the
  problem/progress
• Based on the subjective/objective data
• Diagnosis / progress

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P Plan

• Plan of action that the athletic trainer will
  take to resolve the problem
• Goals immediate, short-term, long-term
• Referrals
• Rehabilitation

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Example 1

• Steve was at basketball practice when he injured
  his right ankle. While driving to the basket he
  said he felt a pop on the outside of his foot.
  Steve stated that his pain was a 6/10. Steve came
  to you with moderate edema and ecchymosis over
  the lateral aspect of his ankle. His range of
  motion was limited, and he tested positive for
  the anterior drawer. You believe he has a grade
  one ATF sprain. Your goal is to RICE Steves
  ankle today and begin rehab in two to three days
  to strengthen the joint.

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Example 2

• Erica is coming in today to finish her gradual
  return to play protocol from suffering her first
  concussion. She reports that her previous syptoms
  are now gone and that everything felt normal.
  Yesterdays exercise session gave her no real
  difficulty, and she felt no new symptoms. Her CSI
  BESS test reports came back normal, and you
  decide she is ready to be cleared to return to
  practice today.

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Example 3

• John came in today to continue treatment he was
  receiving from his grade 2 pec major strain.
  Today he said his pain was a 4/10, and he could
  still feel a sharp pain when he tried to lift his
  arm. He brought his doctor report with him that
  stated John was to be removed from practice for
  four more weeks to allow healing. You observed
  edema and ecchymosis over his right chest, and
  noted that he still had a decrease in range of
  motion in abduction, adduction, flexion, and
  extension of the shoulder. You want to treat John
  today with e-stim and ice and begin a light rehab
  tomorrow to increase range of motion and decrease
  pain.