Terrazzo Presentation

SOAP Notes

Kinesiology I

Objective:

• Understand the SOAP note format.
• Learn the components of SOAP notes.
• Apply SOAP notes to clinical scenarios.

What are SOAP notes?

• structured method for documenting patient evaluations in the medical field
• Enhances clarity, communication, and continuity of care.
• Medical language is used majority of the time with this type of documentation

• S: Subjective
• O: Objective
• A: Assessment
• P: Plan

Subjective (S)

• Patient-reported symptoms and history.
• Example: "I have pain in my right knee after running."
• Importance of listening to the patient.

Objective (O)

• Clinician’s observations and measurable data.
• Example: "Right knee swelling noted; range of motion limited to 90 degrees."
• Includes physical exams and diagnostic results.

Assessment (A)

• Clinical interpretation of subjective and objective data.
• Example: "Likely patellar tendinitis based on history and physical exam."
• Importance of differential diagnoses.

Plan (P)

• Next steps in management and treatment.
• Example: "Prescribe NSAIDs, recommend physical therapy, and schedule a follow-up in two weeks."
• Considerations for patient education and referrals.

Importance of SOAP Notes

• Provides clarity and organization in documentation.
• Ensures continuity of care among healthcare providers.
• Serves as legal documentation of patient interactions.
• Enhances communication in clinical settings

Let's Practce

• In your groups, complete a SOAP note for the following scenario

• Here are some pointers:
• Medical Terminology
• Use your brain
• NO GOOGLE HELP!
• The more details, the better

• SCENARIO:
• 16-year-old male soccer player with left ankle pain after a game.

Questions?