Documentation SOAP Notes Documenting Injury Evaluation Information documentation

  • Slides: 12
Download presentation
Documentation SOAP Notes

Documentation SOAP Notes

Documenting Injury Evaluation Information • ___________________ documentation is critical • Clear, concise, accurate records

Documenting Injury Evaluation Information • ___________________ documentation is critical • Clear, concise, accurate records is necessary for ________ • 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 _____________________________________________

• SOAP Notes • Record keeping can be performed systematically which outlines _____________________________________________ • SOAP notes allow for subjective & objective information, the assessment and a plan to be _________

SOAP- Subjective • History: Attitude, mental condition, and perceived physical state. • ______________ •

SOAP- Subjective • History: Attitude, mental condition, and perceived physical state. • ______________ • Pt. states … • ______________ • My knee is grinding, I am dizzy, my ankle hurts, etc • ______________ • My back started to hurt when I was wrestling a teammate in practice • ______________ • The pain is sharp • ______________ • I can’t point my toes to shoot a soccer ball. • ______________ • Every season in XC, my shins hurt I have had 3 concussions before • ______________ • Sitting makes my hip feel worse but laying down makes it feel a little better

SOAP- Objective: • Observation: ________ objective signs. • • • ______________ Symmetry ______________ Posture

SOAP- Objective: • Observation: ________ objective signs. • • • ______________ Symmetry ______________ Posture and Gait _______________________________

SOAP- Objective q. Rule out Fx (fracture) q______ q. Swelling q______ q. Crepitus q______

SOAP- Objective q. Rule out Fx (fracture) q______ q. Swelling q______ q. Crepitus q______ q. Muscle spasm q______ q. Pulse

SOAP- Objective • ____________ • Active Range of Motion (AROM) • Passive Range of

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

SOAP- Objective • __________ • • __________ Myotomes (_____________) Reflexes Peripheral Nerve Testing •

SOAP- Objective • __________ • • __________ Myotomes (_____________) Reflexes Peripheral Nerve Testing • Sport-Specific Functional Testing • ____________________

SOAP- Objective • Sport-Specific Skill Performance • Throw the football, baseball, softball, javelin. .

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 • ___________ •

SOAP- Assessment • Analyze and assess the individual’s status and prognosis • ___________ • Damaged Structures Involved • __________ • Progress Notes • This is a __________ diagnose. ATC’s can not officially diagnose injuries. • Ex. 1 st degree inversion ankle sprain, TTP at ATF

SOAP- Plan 1. 2. 3. 4. ________ treatment given Frequency and duration of treatments

SOAP- Plan 1. 2. 3. 4. ________ treatment given Frequency and duration of treatments and modalities and evaluation On-going patient education _____________ 5. Ex. Pt. sent home. F/u with MD prior to RTP with – sx of concussion. Met with mom and gave concussion education material. F/u in ER is HA worsens, difficulty staying awake, or becomes unaware of where they are. F/u with ATC tomorrow after school.