The document discusses documenting the evaluation section of a SOAP note. It explains that in the evaluation section, the healthcare professional lists the patient's problem areas at the impairment, functional, and disability levels. They also determine the patient's diagnosis and prognosis. The therapist reviews the history, systems review, and tests and measures to identify functional deficits and impairments. They then list these and explain the relationship between the impairments, deficits, and disability levels. An example is provided of linking specific impairments to functional deficits and how improving the impairments could lead to increased function.

1. Documenting the Evaluation (A)
(Assessment)

2. Assessment
• In the SOAP Note,
• The Evaluation, Diagnosis, and Prognosis parts of
the note are listed in this section
• After a health care professional performs an
examination, the next step is the process of making
clinical decisions.
• This process includes:
• listing the patient’s problem areas:
• deficit at the impairment, functional, and disability
levels
• This process also includes determining the patient’s
diagnosis and prognosis.

3. WRITING THE EVALUATION
(A: EVALUATION)

4. (A: EVALUATION)
• After the therapist completes the examination,
the process of evaluation begins.
• The therapist reviews the:
– History, Systems Review, and Tests and Measures
– Review S and O parts of the note to capture all of
the functionaldeficits and impairments
– These functional deficits and impairments are then
listed.
– After listing the functional deficits and impairments
– Explain the relationship among the impairments,
functional deficits, and disability levels, when
appropriate.

5. (A: EVALUATION)
• Example:
• Pt. has functional deficits in the areas of ambulation c¯ a
walker on level surfaces and stairs, transfers sit ↔ stand,
supine ↔ sit, & on/off toilet.
• Pt.’s functional deficits correspond to the Pt.’s NWB L LE
status & the impairments of ↓ strength of R LE & bilat.
UE musculature & a ↓ in exercise tolerance & muscle
endurance.
• An ↑ in muscle strength & endurance & exercise
tolerance should lead to an ↑ in function.
• Therefore, exercises for strengthening R LE & bilat. UE
musculature & functional activities should lead to an ↑
in strength, muscle endurance, exercise tolerance, &
function.