SOAP Notes - All About SOAP Notes

The SOAP notes is a particular documentation format used by physical therapists and other health care providers, which is a part of the client's medical chart. SOAP is an acronym for subjective, objective, assessment and plan. There are, however, certain differences in informations written on the SOAP notes in different clinical settings. For example, Lachman test, a special orthopedic test for anterior cruciate ligament (ACL) injury may be included in the objective portion by the physical therapist or orthopedic doctor, but not by a nurse.

Parts of the SOAP Note

SOAP notes writing is divided into several parts:

The Subjective part is where patient /client information is written including history of present illness (HPI), past medical history, and family medical history.

Written on the Objective part of the SOAP are tests and measurements done on client, which include vital signs, range of motion (ROM) measurements, PT special tests, manual muscle tests, among others.

Information entered in the physical therapy SOAP Assessment section include list of client problems, goals (Short and Long-term goals if it is an Initial Evaluation) and physical therapist's impression or summary.

The Plan part includes details on the course of treatment that would address the specific client problems listed in the assessment area of your SOAP note.

SOAP Notes Books

Here are some helpful books on how to make an effective SOAP notes presented on our Amazon.com PT Notes Associates Store (Opens on a new window).

Orthopaedic Physical Therapy SecretsEffective Documentation for Physical Therapy ProfessionalsPhysical Therapy Documentation: From Examination to OutcomeHome Care Therapy: Quality, Documentation, and Reimbursement

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