soap note for history taking

1. Musculoskeletal Physical Therapy
SHS.403
Fizza Masood

2. Review Of Previous Topic
• Orthopedic Assessment
• History taking
• Observation
• Examination
• Type of pain

3. Outline Of Topic
• Functional assessment
• Joint position
• Joint play movement
• Diagnostic imaging
• SOAP notes

4. Functional Assessment
• Measurement of a whole-body task
performance ability.
• Relates the effect of the injury on the
patient’s life.
• But first, establish what is important to the
patient.
• Should include repeated movements under
different loads.

5. Joint End Feel (passive ROM)
• The sensation which the examiner feels in the
joint as it reaches the end ROM
• There are 3 normal end feels:
Bone-to bone
Hard & painless (elbow extension)

6. Joint End Feel (passive ROM)
Soft tissue approximation
• movement stops due to soft tissue
compression (elbow & knee flexion)
Tissue stretch
• feeling of a springy or elastic resistance from
the ligaments or capsule (Achilles tendon, or
wrist flexion)

7. Examination of Specific Joints
Passive Movements (cont.)
• End feel:
– Normal:
• Bone to bone
• Soft tissue approximation
• Tissue stretch

8. Examination of Specific Joints
Passive Movements (cont.)
– Abnormal:
• Early muscle spasm
• Late muscle spasm
• Hard capsular
• Soft capsular
• Bone to bone
• Empty
• Springy block

9. Joint End Feel
• Bony block to movement (hard feel)
arthritic joints
• An empty feel or resistance at the end of the
range
may be due to severe pain associated with
infection, active inflammation, or a tumor

10. Joint End Feel
• Springy block (rebound feel) at the knee
torn meniscus blocking knee extension
• Spasm (sudden, relatively hard feel)
muscle guarding
• Hard arrest of movement
capsular involvement

11. Joint Play (accessory) Movements
• The small ROM that can be obtained by the
examiner beyond the active ROM
• Joint dysfunction = loss of joint play
movement
• Joint play mobilization should be done in a
loose packed position

12. Joint Position
• Loose packed
(resting) position = the position at which the
joint is under the least amount of stress
(capsule, ligaments, bone contact).

13. Joint Position
• Close packed position
the position in which the majority of joint
structures are under maximum tension.

15. Examination of Specific Joints
• Diagnostic Imaging:
– Overall size and shape of bone
– Local size and shape of bone
– Thickness of cortex

18. Examination of Specific Joints
• Diagnostic Imaging:
– Trabecular pattern of the bone
– General density of the entire bone
– Local density change
– Margins of local lesions

22. Marginal bone changes and lesions

23. Osteopenia (Reduced bone density)

25. Osteoarthritis

26. Examination of Specific Joints
• Diagnostic Imaging:
– Any break in continuity of the bone
– Any periosteal change
– Any soft tissue change
– Relation among bones
– Thickness of cartilage (cartilage space w/in

30. Examination of Specific Joints
Palpation (cont.)
• Grading tenderness on palpation:
– Grade I: patient c/o pain
– Grade II: pt. c/o pain and winces
– Grade III: pt. winces and withdraws the joint
– Grade IV: pt. will not allow palpation of the joint

32. Definition (SOAP)
•An organized method of documentation used
by providers to describe events involving the
participant.

33. History of SOAP
• SOAP notes were developed by Dr. Lawrence
Weed in the 1960's at the University of
Vermont as part of the Problem-orientated
medical record (POMR).

35. Purpose of SOAP
• SOAP notes are a highly structured format for
documenting the progress of a patient during
treatment and are only one of many possible
formats that could be used by a health
professional.

36. Purpose of SOAP
• They are entered in the patient’s medical
record by healthcare professionals to
communicate information to other providers
of care, to provide evidence of patient contact
and to inform the Clinical Reasoning process.

37. SOAP is an acronym for
• Subjective - What the patient says about the problem /
intervention.
• Objective - The therapists objective observations and
treatment interventions (e.g. ROM, Outcome measures)

38. SOAP is an acronym for
• Assessment - The therapist’s analysis of the various
components of the assessment.
• Plan - How the treatment will be developed to the reach the
goals or objectives.

39. Subjective
• Information obtained from Patient
• Very important to get a good History
– The background of the injury will often give you the
answer.

40. Subjective
• Includes:
– Hx: pertient background information
– MOI or HPI: how, what, when, where of the injury
– C/O: Pt’s sx including description of pain
– Meds: current medications being taken
– All: any allergies

41. Subjective
• Hx:
– PSHx, PFHx, social hx, prev injuries, change in activity,
• MOI:
– Any unusual noises/sensations heard/felt
– Onset of injury: acute or gradual (chronic)

42. Subjective
• C/O: complains of (or chief complaints - CC)
– Pain scale (1-10)
– Location, severity, & type of pain
• Burning, stinging, sharp, dull, deep, nagging, radiating, constant,
@ night, in a.m.
• Pain worse during or after activity
– Limitations from pain
• What aggravates & alleviates pain
• Meds:
• All:

43. Objective information
– Observation and inspection –
– Active motion – least to most provocative
– Passive motion – end feels, Passive vs. active
– Resisted motion – gross movements; mid-range
– Joint play assessment -
– Palpation -
– Neurological tests – referred pain;
– Orthopedic tests
– Other tests as indicated

44. Objective
• Physical findings:
– Everything you observe, palpate, or test
• Typically measurable/repeatable Includes:
– Observation
– Inspection
– Special Tests
– Neurovascular
– ROM
– MMT

45. Objective
• Begins the moment you first see them
– Assess the individual’s state of consciousness & body
language
• May indicate pain, disability, fracture, dislocation, or other
conditions
– Note their general posture, willingness & ability to
move

46. Objective
• When you start your exam:
– Check bilaterally & think outside the box!
– Don’t get caught up in the specific area

47. Observation
• ALWAYS compare bilaterally
• Gait & posture
• Obvious deformity
• Mental alertness – state of consciousness
• Discoloration
• Swelling
• Atrophy/Hypertrophy
• Symmetry
• Scars
• Skin

48. Objective
• Palpation:
–Deformity
–Point tenderness
–Temperature
–Crepitus

49. Objective
• Special Tests: (+/-)
–Fracture tests
–Specific tests for body part
–Functional tests

50. Objective
• (NV) Neurovascular:
– Myotomes - Strength
– Dermatomes - Sensory
– Skin Temp/Color
– Pulse/BP
– Reflexes (superficial & deep tendon

51. Objective
• ROM: (in degrees)
– AROM/PROM
– End feel
• MMT/RROM: (out of 5)
– Strength tests

52. Assessment
• Your professional opinion of the type of injury/illness
• Based on the subjective & objective portions of the
exam
• Include:
– Anatomical location
– Severity
– Description

53. Assessment
– Correlation of subjective and objective findings
– Identification of pathological tissues
– Motivation and emotional status of patient
– Patient’s functional limitations/problem list

54. Plan
• Tx the patient will receive that day
– Ice, splint, crutches
• Plan for further assessment or reassessment
• Patient/Family education: Home instructions
– i.e.: Concussion Take Home Instructions
• Referral

55. Plan
• Short & Long term goals: need to be
measurable
• Expected functional outcomes
• Equipment needs
• Plans for discharge

56. Plan – Treatment/Therapy
• Frequency
• Location
• Duration
• Type
• Progression

57. Plan - Short-term Goals
• Goals that will allow Pt to achieve long-term goals
• Record specific rehab ex’s
• Record any modalities used & exact parameters used
• Day to day or weeks
• Example:
– Increase R shoulder flexion to 145o (from 125o), increase
function so Pt can comb their hair c R hand in 7 days.
– List specific stretching & functional exercises

58. Plan - Long-term Goals
• Expected outcomes
• Includes:
– What is the outcome
– What will it take to achieve that outcome
• Include measurements and specific interventions for each goal
– What conditions must exist for a good outcome

59. Plan - Long-term Goals (cont.)
• Example:
– Return to full strength (5/5 from 4/5), full ROM
(170o from 145o), return to volleyball
– List specific strength ex’s, stretches, & sport
specific activities

60. Ending the consultation
• The end of a consultation is important for two
reasons:
you need to check that the information you have
is complete and accurate the patient needs to
know what will happen next
All consultations should have a definite
conclusion.

62. Summary