SOAP NOTES Name Date: Instructions: Write “S" for Subjective or “0” fr Objective 1. Patient's Range of Motion a 2. The mechanism of injury (patient a explaining how injury occurred) a 3. Description of pain aan A. Palpation of injury (feeling the injury with your hands) a __5. Patient gives medical history ___6. Patients Blood Pressure and Pulse oi 7. "The pain started yesterday around noon.” a) 8. ‘On sat recorded at 97%" oe 9. "fray showed no fractures” i 20, 10. "My pain is about a 6 out of 10.” 21, Place an "x" next to the statement that is more "OBJECTIVE". “tis more of a dull aching pain” "inch laceration on right hand.” “Lab results were negative.” “ft take an Advi the pain usually goes away.” “Age: 46 Height: 5/6" Weight: seals" “Patient appears pale and in discomfort.” “Abdomen soft and non-tender.” “feel nauseated. “Pulse irregular® “Lam feeling dizzy" Gl “Patient was unable to complete a simple cooking task* 2 “Patient is dependent in ali cooking taska* 22, Place an “X" next to the statement that is mare “OBJECTIVE”. 1 “Stomach pain at a level 8° 1 Abdominal tenderness when pressure applied” 23, Place an “x” next tothe statement that is more "OBJECTIVE". “Binge taking nex pre-seription, patient's resting heart rate has Increased by 2.0bpn* i *Sinte taking new preseription, patient has been experienting heart palpltations*Instructions: Wite “A” for Assessment or “P” fo Plan 24, “Major Depressive Disorder, recurrent, without psychotic features.” 25, “The prognosis for the patient at this time is good because the patient is responding well to treatment.” 26. “Will continue to monitor patient” 27. "Continue Fluoxitine at 10mg dose.” 28, "Transverse fracture ofthe distal tbl.” 29, "Referred patient to a dentist.” 30. "Provided low-sadium handout to patient.” 31, “Continue current Physical Therapy.” 32. "Patient desires to return to work but does not yet demonstrate the capacity for the required sitting tolerance.” 33, "Recommended the use of lumbar support and regular performance of home program.” 34, “Asthmatic- exercise induced.” 35. “Kray to rule out fracture.” 36, Place an “x” next tothe statement that would be the most aperopriate way to write an ASSESSMENT. “Patient 1s improving? 1 “Patient inoreased ROM 10 de grees.* 37, Place an “x” next tothe statement that would be the most appropriate way to write an ASSESSMENT. Gl *Pationt had ditFieulty with blook stacking aetivity this session which Was mastered (ast session 1 “Patient showed a decrease in aesuracy over the last session.* 38, Place an “x’ next to the statement that would be the most appropriate way to write a PLAN. O “Inorense physical therapy to more times per week." i “Have patient supplement PT with at-home exersises given by Physical Theraplst:* 439, Place an “x” next tothe statement that would be the mast appropriate way to write @ PLAN, 1 “Continue taking medications as prescribed.” “Consider changing meditation dosage.”UNLUCKY LUK You are the Athletic Trainer on the sidelines for @ game and see the running back, 18-year-old Luke Adamgo, fll to the ground after a play is over grasping his eft ankle, You run over to check on him and he said that he twisted his ankle when he made a quick move and felt a “pop”. He tells you the pain is. Intense, and itis starting to feel numb. When you asked how bad the pain was on a scale of 10, he said a "9". Upon Inspection, its beginning to swell on the lateral side of his ankle. You ask him to dorsiflex and plantar flex and he is unable to move it without extreme pain. You stand him up and he is also unable to put any weight ‘oni. You and one of the other Athletic Trainers carry him to the sidelines. Upon palpation, he has tenderness and pain on the lateral malleolus as well as the distal fibula, You run a hee! tap test to check for a possible fibula/tibia fracture. He did not feel pain, which resulted in a negative result. Next, you run a Talar Tit Test and felt no major endpoint- leading to a positive result Even though you are not able to make an offical diagnosis, you know these results indicate a potential sprain of his CFL (calcaneofibular ligament). You immediately place ice on the Injury, lie him down and elevate his ankle. You apply an ACE bandage snug, but not tight, around his ankle. One of the Athletic Training Assistants runs, and {grabs crutches and his parents are called down from the stands. You tell them to take Luke to the Emergency Room for further evaluation and to continue with Rice, Ice, Compression and Elevation of his ankle. Using the description from the scenario above, use the SOAP notes worksheet to properly fill inthe incident that took place.mwa Creek SOAP NOTE me mae Date - SUBJECTIVE OBJECTIVE ASSESSMENT PLAN Signature: Dat |