NAME ______

SOAP NOTES

S = Subjective = what the patient tells you

O = Objective = information that can be measured

A = Assessment = what can be decided based on what you know

P = Plan = Course of Treatment

In what section do these notes go into? S, O, A, or P?

a. _____ Knee flexion = 110°

b. _____ Patient’s finger appears swollen and bruised

c. _____ Instruct patient to continue RICE for next 24 hours

d. _____ Patient reports falling and twisting ankle while playing soccer

e. _____ Decreased sensation on right medial forearm

f. _____ Increase range of motion and strength, left shoulder

g. _____ Pain reported while going up and down stairs

h. _____ PT Diagnosis = ruptured Achilles tendon

NAME ______

Scenario #1

A sprinter explodes out of the blocks but pulls up after only 15-20 meters, grabbing the back of her thigh. The sprinter limps off the track complaining of severe pain and the inability to bend her knee without pain. Touching her toes is also very painful. There is some mild discoloration/bruising observed. She is tender to palpation, and a noticeable defect in the muscle tissue is felt. The examiner suspects this athlete has a moderate (Grade II) hamstring strain. An ice pack and compression with an elastic wrap is applied and the leg is elevated for 15-20 minutes. She is given instructions to continue to ice regularly and begin gentle stretching of the area. Once the soreness is minimized, a rehabilitation program will be initiated.

SOAP Note scenario #1

SUBJECTIVE: Patient Description______

OBJECTICE: Measurable, Observable Findings

______

ASSESSMENT: Professional Opinion

______

PLAN: Treatment, Frequency, Short-Term Goals, Long-Term Goals

______

NAME ______

Scenario #2

A hockey player was taking a shot on goal when his stick hit the jaw of the player who was guarding him. That player comes off the ice bleeding from the mouth, complaining of pain in his lower jaw and an inability to close his jaw (malocclusion). Upon palpation by the examiner, deformity and swelling are noted. Discoloration around the jaw and facial distortion are observed. The examiner suspects this athlete may have a fracture of the mandible. The bleeding is controlled, the jaw is immobilized, and the athlete is immediately referred to an emergency room.

SOAP Note scenario #2

SUBJECTIVE: Patient Description______

OBJECTICE: Measurable, Observable Findings

______

ASSESSMENT: Professional Opinion

______

PLAN: Treatment, Frequency, Short-Term Goals, Long-Term Goals

______

NAME ______

Scenario #3

A quarterback is charged by the defense as he is preparing to throw a pass and is struck in the throwing arm, forcing it into external rotation, abduction and extension. He reports an immediate burning sensation traveling down his arm and now his thumb is tingling. The examiner notes muscle weakness involving the shoulder and arm muscles and pain above the clavicle. No deformity or swelling is palpated. Within 10 minutes, the pain and burning sensation resolves. The examiner rechecks neck and shoulder range of motion, strength of the shoulder and arm muscles, and grip strength. All appear to be normal. The examiner believes this athlete has had a brachial plexus injury (stinger). Since the athlete’s symptoms have all cleared and returned to normal, the athlete is allowed to return to the game. An additional exam to recheck this athlete will be conducted at the end of the game.

SOAP Note scenario #3

SUBJECTIVE: Patient Description______

OBJECTICE: Measurable, Observable Findings

______

ASSESSMENT: Professional Opinion

______

PLAN: Treatment, Frequency, Short-Term Goals, Long-Term Goals

______

NAME ______

Scenario #4

A female distance runner is complaining of a deep, aching pain in the knee during activity. She cannot recall any injury to her knee. She has increased her running distance from 4 miles/day to 6 miles/day in the past week and has been running on varied surfaces. She also complains of pain during ascending and descending stairs. After practice, she has been applying ice to her knee and taking ibuprofen. Observation reveals no postural abnormalities other than slight joint effusion. As the examiner palpates the patella, the athlete reports pain and tenderness when the patella is pushed downward. She also reports discomfort when the patella is moved medially and laterally. During passive knee extension, the patella laterally deviates from the groove. Pain increases during resisted knee extension, and crepitus occurs under the patella. She cannot perform a duck walk or squat test without pain. You believe that this athlete may have Chondromalacia (a degenerative condition in the articular cartilage of the patella). You decide to design a rehabilitation plan for this athlete including quadriceps and hamstring flexibility and strengthening, specialized taping, and other appropriate procedures.

SOAP Note scenario #4

SUBJECTIVE: Patient Description______

OBJECTICE: Measurable, Observable Findings

______

ASSESSMENT: Professional Opinion

______

PLAN: Treatment, Frequency, Short-Term Goals, Long-Term Goals

______