SOAP Notes and the PTA

Subjective information includes specific types of information related to the patient. Choose the statement that would be included in this part of the documentation.

• The patient will continue to be seen 2x/week.

• The patient was able to ambulate (I) 20 feet using a front-wheeled walker.

• The patient reported his pain level prior to treatment was a 6/10 on the VRS.

• The patient will be referred to OT for a hand splint

What type of listening technique is used in response to a specific question asked of a patient?

• Analytic listening

• Exploratory listening

• Directed listening

• Appreciative listening

We determine a patient's pain level using many tools. What is the MOST commonly used tool to assess this subjective response?

• Body Drawing

• Body Shaming

• Pain Profile

• Verbal Rating Scale

If the patient cannot verbally communicate with you, how can you BEST determine what his or her pain level might be prior to, during, or following treatment?

• The patient can point to a symbol that identifies his or her pain level.

• The patient does not have to report his or her pain level if it cannot be communicated verbally.

• A family member or the caregiver can provide the pain level for the patient.

• The patient can use Morse Code to tap out his or her pain level.

Identify the MOST appropriate subjective statement to be included in a SOAP note.

• "My left hip hurts because I fell last night."

• "I drank too much last night and have a hangover."

• "I took my driver's license exam this morning."

• "My brother is coming to visit this week."

When writing subjective information, it is important to use relevant verbs when describing the patient's responses. These words should be related most often to the functional goals written in the plan of care. Choose the statement that uses the words BEST to meet this criterion.

• The patient reports that his wife is always nagging him.

• The patient states that he would like to be able to go drinking with his buddies, again.

• The patient stated that she wants to be able to walk up and down the two steps into her house.

• The patient is eating all foods by mouth.

Identify the statement below that would be included in the objective section of the SOAP note?

• The patient stated his pain level was a 5/10 following the treatment session.

• The patient reported that he can use his walker to get to his car now.

• The patient was able to perform AAROM to (R) shoulder, flex. 0º to 180º, 10 reps, 3 sets.

• The patient plans on seeing his doctor next week for a follow-up visit.

Identify the statement below is the LEAST appropriate objective response.

• The patient performed 10 reps, 3 sets of (B) elbow flexion.

• The patient ambulated (I), 20 ft. using FWW, SBA 1x.

• The patient performed (I), AROM in shoulder ext., prone, 10x, 1 set.

• The patient transferred (I), from EOB to w/c using stand-pivot transfer x 2.

Which of the following statements includes ONLY parameters that would be included in the objective section of the SOAP note.

• Vital signs, measurements, plan of treatment

• Blood pressure, ROM, recommendation for change in plan of care

• Oxygen saturation level, wound size, position of the patient

• Referral to another discipline, strength measurements, stride length

Why is it important to describe the patient's level of function in the objective section of the SOAP note?

• It helps determine how much pain the patient is experiencing.

• It will help determine what services the patient needs.

• This information is not necessary in this section of the SOAP note.

• It will help the therapist determine if the level of function improves.