Documentation SOAP notes

Report
DOCUMENTATION
MEDICAL TERMINOLOGY
MEDICAL TERMINOLOGY
• WHY ARE ABBREVIATIONS, SYMBOLS AND ACRONYMS USED IN HEALTH CARE?
MEDICAL TERMINOLOGY
• PRONE
• SUPINE
• INFLAMMATION
• HYPERTONIC VS. HYPOTONIC
• ETC…
MEDICAL TERMINOLOGY AND ABBREVIATIONS
• MAKE FLASH CARDS
ASSIST
A
AFTER
p
abd.
•ABDUCTION
ADL’s
•ACTIVITIES OF DAILY LIVING
Add.
•ADDUCTION
AROM
•ACTIVE RANGE OF MOTION
AKA
•ABOVE KNEE AMPUTATION
@
•AT
BILATERAL
B
BKA
•BELOW KNEE AMPUTATION
BIW
•BI-WEEKLY, TWICE WEEKLY
CG
•CONTACT GUARD
CP
•COLD PACK
C/O
•COMPLAINS OF
DC
•DISCHARGE
DF
•DORSIFLEXION
DX
•DIAGNOSIS
ER
•EXTERNAL ROTATION
FWB
•FULL WEIGHT BEARING
FX
•FRACTURE
HEP
•HOME EXERCISE PROGRAM
HX
•HISTORY
INDEPENDENT
I
IE
•INITIAL EVALUATION
IR
•INTERNAL ROTATION
LEFT
L
LBP
•LOW BACK PAIN
LE
•LOWER EXTREMITY
LTG
•LONG TERM GOAL
MHP
•MOIST HOT PACK
MMT
•MANUAL MUSCLE TEST
NWB
•NON WEIGHT BEARING
PF
•PLANTAR FLEXION
PMH
•PAST MEDICAL HISTORY
Pt.
•PATIENT
PWB
•PARTIAL WEIGHT BEARING
RIGHT
R
Reps
•REPETITIONS
Rx.
•TREATMENT
SBA
•STANDBY ASSIST
SI, SIJ
•SACROILIA JOINT
STG
•SHORT TERM GOALS
TENS
•TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION
THR
•TOTAL HIP REPLACEMENT
TIW
•THREE TIMES A WEEK
TKR
•TOTAL KNEE REPLACEMENT
UB
•UPPER BODY
UE
•UPPER EXTREMITY
WB
•WEIGHT BEARING
WBAT
•WEIGHT BEARING AS TOLERATED
WNL
•WITHIN NORMAL LIMITS
WITHOUT
s
WITH
c
CHANGE
INCREASE/DECREASE
CHIEF COMPLAINT
•CC
AS NEEDED
•PRN
SIDELYING
•S/L
STRAIGHT LEG RAISE
•SLR
SIDEBEND
•SB
LUMBAR SPINE
•L/S
CERVICAL SPINE
•C/S
ILIO-TIBIAL BAND
•ITB
STANDARD WALKER
•SW
ROLLING WALKER
•RW
THERABAND
•T-Band
PRACTICE…
• Pt. c/o LBP along the R side.
_
• Rx c MHP
• Pt. given HEP.
S.O.A.P. NOTES
S.O.A.P. NOTES
• SUBJECTIVE
• OBJECTIVE
• ASSESSMENT
• PLAN
S.O.A.P. NOTES
• WHAT IS THE DIFFERENCE BETWEEN SUBJECTIVE INFORMATION AND OBJECTIVE
INFORMATION?
• HOW IS EACH IMPORTANT IN DOCUMENTATION?
S.O.A.P. NOTES
• THE “SUBJECTIVE” PART OF THE SOAP NOTE:
• IS WHERE YOU WRITE WHAT YOUR CLIENT HAS TO SAY ABOUT HIS OR HER CURRENT CONDITION.
"I CAN NOW BEND MY BACK TO PUT ON MY SOCKS AND SHOES FOLLOWING MY TREATMENT
SESSION YESTERDAY."
IT IS BETTER IF THE PATIENT'S SUBJECTIVE STATEMENT IS MORE SPECIFIC.
• "THE PAIN ON MY BACK HAS MOVED DOWN TO 3/10 FROM THAT OF YESTERDAY BEFORE MY
TREATMENT."
S.
O.A.P. NOTES
• THE "OBJECTIVE" PART INCLUDES ALL THE MEASUREMENTS THAT YOU'VE OBTAINED FROM
YOUR CLIENT.
• THIS INCLUDE THE VITAL SIGNS, MANUAL MUSCLE TESTING MEASUREMENTS, JOINT RANGE OF
MOTION MEASUREMENTS, ETC.
THE SPECIFIC PHYSICAL THERAPY TREATMENTS ARE ALSO INCLUDED IN THE OBJECTIVE PART.
THE TREATMENT SHOULD INCLUDE THE SPECIFIC WEIGHT, REPETITIONS, INTENSITY AND DURATION.
S.
O.A.P. NOTES
_
• ® KNEE EXTENSION- FULL ROM; 10 REPS X 3 SETS c 5 LBS. ANKLE WEIGHT
• MHP ON B LUMBAR AREA x 20 MINUTES
S.O.
A.P. NOTES
• ASSESSMENT
THIS IS WHERE THE PHYSICAL THERAPIST WRITES HIS/HER IMPRESSION REGARDING PATIENT'S
CURRENT SITUATION SINCE LAST VISIT.
• THIS MAY ALSO INCLUDE THE THERAPIST'S PERSPECTIVE ON WHETHER A PARTICULAR TREATMENT
WILL BE CONTINUED OR MODIFIED ACCORDING TO CLIENT'S NEEDS.
EXAMPLE: "The Pt. tolerated the Rx well but needs frequent verbal cues from PT to complete knee
extension at full ROM."
S.O.A.
P. NOTES
• PLAN
IN THE PLAN PART, THE PHYSICAL THERAPIST WRITES THE PLANS FOR THE CLIENT'S NEXT
THERAPY VISIT.
SAMPLE SUBJECTIVE DATA
• 24 y/o male c/o L ankle pain. Pt. states he was playing basketball this morning, when he jumped
to block a pass and "came down funny" on his ankle. He states pain goes from a dull 2 out of 10
to a sharp 6 out of 10 when he applies pressure. Pt. has no allergies to medications, and is currently
taking Advil for a previous injury of R knee.
THE KNEE
-Largest
joint in the body.
-Hinge joint
-greatest ROM is in flexion
-highly susceptible to injury
-not protected by layers of
fat and muscle
-easily palpable
THE KNEE (ANTERIOR)
THE KNEE (POSTERIOR)
THE KNEE
THE KNEE
THE KNEE
BURSAs
KNEE LIGAMENTS
• HTTP://YOUTU.BE/RRVAJHJXMX8
• HTTP://YOUTU.BE/HWNFGM6JIKY
• HTTP://YOUTU.BE/OUIIXMGTLYI

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