Orthotic fitters course SOAP notes
SOAP - answer• S = Subjective
• O = Objective
• A = Assessment
• P = Plan
SUBJECTIVE - answer-What happened
-How it happened
-Patient's descriptions
-Where it happened (e.g. surface, weather conditions, etc.)
-When it happened
-Previous history
-Any unusual noises/sensations heard/felt
-What treatment has been done for it
-Etc.
OBJECTIVE - answerEverything you SEE and DO
Results of limitations, instability, apprehension
› General appearance (discoloration, deformity, rigidity) › Edema (swelling) ›
Temperature › ROM › Gait analysis › Method of transport to you › Muscle strength ›
Muscle tone
› Posture › Endurance › Sensation › Mental alertness › Respiration › Pulse ›
Skin/wounds › Stress tests (reflexes, specific tests for body parts) › Functional tests
ASSESSMENT - answerYou will want to document your assessment of the condition
you are dealing with. This would be your educated guess of what is going on.
PLAN - answer• Treatment the patient will receive - First aid treatment, splint, wrap,
crutches, re-evaluate tomorrow a.m.
• Short & Long term goals
• Expected functional outcomes
• Frequency per day/week
• Treatment progression
• Patient education - home instructions
• Referral
• Discharge notes
The SOAP note should briefly express the following: - answer• Date and purpose of the
visit, patients symptoms and complaints.
•The current physical evaluation, include height, weight, age.
• New results of studies, reports, assessments, physicians orders.
•The current formulation and plan for the patient.
SOAP - answer• S = Subjective
• O = Objective
• A = Assessment
• P = Plan
SUBJECTIVE - answer-What happened
-How it happened
-Patient's descriptions
-Where it happened (e.g. surface, weather conditions, etc.)
-When it happened
-Previous history
-Any unusual noises/sensations heard/felt
-What treatment has been done for it
-Etc.
OBJECTIVE - answerEverything you SEE and DO
Results of limitations, instability, apprehension
› General appearance (discoloration, deformity, rigidity) › Edema (swelling) ›
Temperature › ROM › Gait analysis › Method of transport to you › Muscle strength ›
Muscle tone
› Posture › Endurance › Sensation › Mental alertness › Respiration › Pulse ›
Skin/wounds › Stress tests (reflexes, specific tests for body parts) › Functional tests
ASSESSMENT - answerYou will want to document your assessment of the condition
you are dealing with. This would be your educated guess of what is going on.
PLAN - answer• Treatment the patient will receive - First aid treatment, splint, wrap,
crutches, re-evaluate tomorrow a.m.
• Short & Long term goals
• Expected functional outcomes
• Frequency per day/week
• Treatment progression
• Patient education - home instructions
• Referral
• Discharge notes
The SOAP note should briefly express the following: - answer• Date and purpose of the
visit, patients symptoms and complaints.
•The current physical evaluation, include height, weight, age.
• New results of studies, reports, assessments, physicians orders.
•The current formulation and plan for the patient.
