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What must subjective info be relevant to?
pt. diagnosis and treatment
Is it ok to not fill out the subjective portion of the note if there is no new information?
yes - "no new comments"
What type of words do you want to use in the note?
verbs - states, reports, complains of, expresses, describes, denies
What do you do if someone else is providing patient info?
state who provided it and why the patient couldnt provide it
Are pain measurements subjective?
What is included in objective data?
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
What is objective data?
- *just the facts!!*
- any info that can be reproduced or observed by someone else with the same training
What content is included in the assessment section?
diagnosis, functional outcomes, goals, treatment effectiveness
What is assessment data?
- "what does it mean?"
- interpretation and significance of S and O
- describes pt response to tx plan and pts progress toward accomplishing goals
Which section of the SOAP note is most important?
What does the assessment section summarize?
- 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
What info is included in the A section?
- change in impairment
- progress toward functional outcomes and goals
- lack of progress toward goals
- inconsistency in data
The A section simply informs the reader of what?
the effectiveness of the PT plan of care
What is the plan section contain?
- 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
What tense is used in the plan section?
future tense - what will happen
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