Documentation SOAP Notes Documenting Injury Evaluation Information Complete

Documentation SOAP Notes

Documenting Injury Evaluation Information • Complete and accurate documentation is critical • Clear, concise, accurate records is necessary for third party billing • While cumbersome and time consuming, athletic trainer must be proficient and be able to generate accurate records based on the evaluation performed

• SOAP Notes • Record keeping can be performed systematically which outlines subjective & objective findings as well as immediate and future plans • SOAP notes allow for subjective & objective information, the assessment and a plan to be implemented

SOAP- Subjective • History: Attitude, mental condition, and perceived physical state. • • Stated by the athlete. Primary Complaint Mechanism of Injury Characteristics of the Symptoms Limitations Past History Type of pain? What makes it better? Worse?

SOAP- Objective: • Observation: Measurable objective signs. • • • Appearance Symmetry General Motor Function Posture and Gait Deformity, swelling, discoloration, scars, and general skin condition

SOAP- Objective q. Rule out FX (fracture) Cutaneous Sens. q. Skin temperature Pulse q. Swelling q. Point tenderness q. Crepitus q. Deformity q. Muscle spasm

SOAP- Objective • Functional Tests • Active Range of Motion (AROM) • Passive Range of Motion (PROM) • Resisted Manual Muscle Testing (RROM) • Stress Tests • Ligamentous Instability Tests • Special Tests

SOAP- Objective • Neurologic Tests • • Dermatomes Myotomes Reflexes Peripheral Nerve Testing • Sport-Specific Functional Testing • Proprioception and Motor Coordination

SOAP- Objective • Sport-Specific Skill Performance • Throw the football, baseball, softball, javelin. . . • Kick the soccer ball, football, opponent…

SOAP- Assessment • Analyze and assess the individual’s status and prognosis • Suspected injury Site • Damaged Structures Involved • Severity of Injury • Progress Notes

SOAP- Plan 1. Immediate treatment given 2. Frequency and duration of treatments and modalities and evaluation 3. On-going patient education 4. Criteria for discharge/return to play