SOAP info.txt

pt. diagnosis and treatment

yes - "no new comments"

verbs - states, reports, complains of, expresses, describes, denies

state who provided it and why the patient couldnt provide it

yes

results from measurements and testsdescription of pts functioninterventions performedpts responsePTAs objective observations of ptrecord of number of treatment sessions providedsimilar info grouped together, and flows from one topic to the next

• *just the facts!!*
• any info that can be reproduced or observed by someone else with the same training

diagnosis, functional outcomes, goals, treatment effectiveness

• "what does it mean?"
• interpretation and significance of S and O
• describes pt response to tx plan and pts progress toward accomplishing goals

assessment

• whether PT is helping the pt
• PTAs summary of note with comments about the relevance and meaning of info
• pts response

*must be supported by subjective and objective info

• change in impairment
• progress toward functional outcomes and goals
• lack of progress toward goals
• inconsistency in data

the effectiveness of the PT plan of care

• what will be done next section
• when next session is scheduled
• what PT consultation or involvement is planned
• equipment or info that needs to be ordered
• number of tx sessions remaining before discharge

future tense - what will happen