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SOAP Assessment Notes

SOAP notes are a structured documentation method used in healthcare, consisting of four sections: Subjective, Objective, Assessment, and Plan. Each section captures patient-reported information, measurable data, clinical impressions, and management strategies, respectively. This approach enhances communication among providers and supports continuity of care in physiotherapy.

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9 views2 pages

SOAP Assessment Notes

SOAP notes are a structured documentation method used in healthcare, consisting of four sections: Subjective, Objective, Assessment, and Plan. Each section captures patient-reported information, measurable data, clinical impressions, and management strategies, respectively. This approach enhances communication among providers and supports continuity of care in physiotherapy.

Uploaded by

Akshara
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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SOAP Assessment - Detailed Notes

Introduction
SOAP notes are a structured method of documentation used by healthcare professionals,
especially in physiotherapy, nursing, and medicine. SOAP stands for Subjective, Objective,
Assessment, and Plan. This format ensures a systematic approach to patient care and
communication among professionals.

1. Subjective (S)
This section contains the patient’s own report of symptoms, concerns, and experiences. It is
qualitative and based on what the patient communicates. - Patient’s chief complaint (reason for
visit) - History of presenting illness (onset, duration, severity, aggravating/relieving factors) - Past
medical and surgical history - Functional limitations in daily activities - Patient’s goals and
expectations Example: “The patient reports pain in the lower back for the last 2 weeks, worsens
with bending and improves with rest.”

2. Objective (O)
This section includes measurable, observable, and reproducible data collected by the therapist. -
Vital signs (BP, HR, RR, temperature, SpO■) - Physical examination findings (posture, gait, muscle
tone, ROM, strength) - Neurological findings (reflexes, coordination, balance) - Functional
assessment (mobility, ADLs) - Results of special tests, lab investigations, or imaging Example: “BP:
120/80 mmHg, HR: 78 bpm, Lumbar flexion limited to 60° with pain.”

3. Assessment (A)
This section synthesizes subjective and objective findings to form a clinical impression. - Diagnosis
(physiotherapy perspective) - Problem list (primary and secondary impairments) - Patient’s
response to treatment - Prognosis (short- and long-term outcomes) Example: “Findings suggest
mechanical low back pain likely due to poor posture and muscle imbalance. Good prognosis with
physiotherapy.”

4. Plan (P)
This section outlines the management strategy based on assessment findings. - Short-term goals -
Long-term goals - Treatment plan (modalities, manual therapy, therapeutic exercise, education) -
Frequency and duration of sessions - Home exercise program (HEP) Example: “Plan: 3
physiotherapy sessions/week for 4 weeks, focus on core strengthening, posture correction, and
ergonomic advice.”

Conclusion
SOAP notes provide a clear, organized, and standardized documentation method that improves
communication among healthcare providers and ensures continuity of care. In physiotherapy, they
help track progress and guide evidence-based interventions.

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