SOAP Note Midterm

Diagnosis:

Wellness Service Start Date:

Session #:

Today’s Date:

Precautions:

S:

O:

Data Collection:

BP:

HR:

RR:

O2 sats:

Girth Measurements:

Therapeutic Exercise: Examples of format and how to write out exercises.

HEP: Was it reviewed? What exercises? How many reps? Quantify v/c or t/c needed (% of time or min, mod, max).

Supine:

· Bridging 3x10 reps and min v/c for increased hip extension AROM

· Ankle pumps, QS, glute sets 3x10 reps

Seated:

· B LE LAQ 3x10 reps with min v/c for improved eccentric control

· B UE scapular row 2# t-bar 3x10 reps

Standing: All exercises performed in // bars or EOB, etc. and include assist

· Mini-squats c light B UE assist, 2x15 reps, SBA for safety, v/c 50% of time for proper technique

· B LE hip ab/ad 3x10 reps, SBA

Therapeutic Activity:

· Dynamic stand bal. on foam mat tossing ball, x3’, CGA, LOB 25% of time

· Monster walk c light orange resistance band at ankles, 20’x4 reps, SBA, v/c 20% of time to increase stride length, no LOB noted

Neuromuscular re-education:

· Unsupported static balance EOB x7’, Mod Ax1 to prevent posterior lean/LOB, v/c and t/c 75% of time

Gait Training:

· Amb s AD, SBA 150’x2, forward flexed posture at trunk, v/c 25% of time, no LOB noted

· Amb c B UE canes to promote reciprocal arm swing, CGA 150’x2, no LOB noted

Manual therapy:

· B LE passive HS stretch 3x10 sec holds

· STM to R upper trap x15’

· STM/cross friction, to anterior L LE TKA incisional scar.

Physical Agents:

· US R lat. knee, LCL, supine, 0.5 W/cm2, pulsed 20%, 3MHz, 5min.

A: Focus on 1-2 areas of the tx session, try to limit to 3-5 sentences and provide evidence to back up why therapy is indicated. Also keep in mind this is a legal document and the insurance company will approve more tx visits based on your assessment.

Ex: Pain decreased following today’s session. Attempted LAQ with ankle weight on L LE, exercise was modified due to leaning compensatory strategies through ROM secondary to L LE weakness. Client tolerated supine manual HS stretch well, may benefit from contract relax supine HS stretch to assist with decreasing LBP and promote improved postural alignment which will increase daily functional abilities. Client required mod v/c to maintain upright posture for seated HS stretch and extend knee. Client will benefit from cont education on proper form/technique with seated HEP HS stretch.

Goals: copy and paste from initial evaluation, address in the assessment if any goals were met and if new goals are written (by the PT).

Ex. of how to address a goal that’s been met.

1. Client will amb c FWW 150’x1, min Ax1, LOB <50% of time. GOAL MET

Revised goal (by the PT): Client will amb c FWW 150’x1, CGA s LOB.

P: The plan gives direction to the next therapist. What should they continue to work on, should they advance an exercise, is more pt. education needed and in what area, etc?

Example:

Review HEP monitoring for correct posture and technique. Progress to contract/relax supine HS stretch to increase flexibility for decreased LBP. Continue working sit/stand on low surface heights to gain proper form/decrease LBP.

Billing: Description and Units

Remember CARE Clinic “bills” in 15’ units, and we see clients for approx. 1 hour.

Example: 1 TA, 1 TE, 2 GT

Signature and Date:

Mark Smith, SPTA 9/4/2019