- Hi, I'm Bob Schrupp physical therapist
- Brad Heineck, physical therapist
- Together we are the most famous physical therapist
on the internet
- In our opinion, of course, Bob.
- So Brad, we had a request
- Right? As you know, we've got a number of students
that watch our videos and this particular student says
are you gonna do one on SOAP notes?
- All right.
- And both you and I that
it was a little bit troublesome that it was for me.
- Sure.
- How do you do a SOAP note
- Getting started on one, and it's not the worst
for people who don't, you know, that aren't students.
They can see how we document things,
how we talk about people.
- And these soap notes are something that nurses use,
OTs, PTs, a lot of people in the health field.
And what do they mean by soap?
We're talking about subjective S,
objective O, A is your assessment, and P is the plan.
Now I'm not even gonna go through this
in a lot of detail, Bob, but these are things that helped me
out when I started this to make them efficient
and a nice clean note.
- Can you read this okay, Lonnie, by the way.
Oh, we're at the right angle.
Okay.
- Yeah. It's my writing, it's not very clear.
That's why I dictate everything.
- So subjective is first.
- Right and I always start out with this sentence.
Well, it depends on the gender.
Patient is a pleasant 41 year old male with complaints
of low back pain.
It puts it out right away.
You have a picture of who this person is.
Sometimes they'll put in there
if there's slender obese or something of that nature.
- Right and you got the age in there.
So they, you right away know where you
you are, you know, demographically wise.
- Exactly. And we know the basic complaint.
It's low back pain and we're not gonna get specific yet.
And then my second sentence.
- So if they're unpleasant, you put unpleasant.
- Yes. You better believe I do.
- All right.
- It's important to know if the therapist next, you know
who treats them next is kind of prepared for that.
- Maybe agitated you might put or
- Yeah. Right.
- Descriptive
- Be professional.
Yep. Then next sentence will be primary-
- Objective.
- No, I go, the next sentence, I go to the primary part
of the subjective primary complaint
of low back pain with sitting.
- And there may be some other things, but that's so
you get right to the point and then you can add
in some fillers, if you want to
- Sure.
- This is the way I do it.
Bob can fill in how, how you like to do yours.
- Sure.
- Then objective, and this varies from therapists
to therapists, but it's always things you can measure.
Very objective things
like range of motion, you can measure.
If there's point tenderness
at what location is that L4 L5, you know
in the sacroiliac area, neuro tests, if you're gonna do
some neuro tests with your reflex hammer
manual muscle testing, you got some muscle grades,
four out of five, three out of five, other special tests.
You got any other ones that
- No, that, that covers most of them, the objective
tests you're gonna do, especially with back pain.
Now, if someone else had a balance problems, then
you you'd be doing some balance tests and stuff like that.
So depending on the problem.
- And then the assessment part
and this is where the first thing I always
write down are symptoms are consistent with
- Right?
- We are not doctors.
We are
- Not, not allowed to diagnose.
- Right.
- So we can assess.
And which means, again
he's saying this is acting like it could be this.
- Right, so it's a very clear way to put it
and it makes it legally acceptable
if you ever had to go to court
- Right.
- You'd say, well, the symptoms were consistent
with L5 herniated discs.
- Right, We're not saying it is because we didn't have
MRI or CT scan, so
- Right. And then you may do a little more
a few more sentences to carry details out on that.
And then goals.
I like to keep in the assessment part or just after that
I like to keep it down to three goals.
Some people do more.
A nice one if it's an outpatient
- Some people might put short term goals
and long term goals.
- Yeah. I usually do three short term and one long term
Other people do more.
This is simple.
The first one for an outpatient demonstrate
independent home exercise program.
Almost all people need to do that.
It's an easy goal and it's, it is worthy.
Next one in this particular one sit greater
than 20 minutes without low back pain.
Function. Okay.
I'm not gonna say patient able to flex more
than 30 degrees forward without back pain.
- And really quite often you wanna have the goals
really oriented towards function as much as possible.
- Because insurance companies don't care.
If you can flex up the 60 degrees without pain
but they do care if you can sit for more than 20 minutes.
- Or pick something off the floor.
- Right, especially if the person works
at a job where they sit all the time
- And the short term goals probably should be
something you can reach within like two
one to two to three weeks.
- You're right.
And then the last one I put another example
to put shoes on in the seated position.
- Sure, again, functional tasks.
That's what you wanna think. Function, function, function.
- I'm not gonna put patient failed to touch toes
in the seated position, cuz why would you touch your toes?
But you do need to put your shoes on every day.
- Last one is plan.
- Plan. And this is how are you gonna get there?
- In this case-
- How are you gonna get to your goals
- Exactly, in this case,
progressive lumbar extension range of motion
and then another educate patient on biomechanics and posture
to help reduce pain and symptoms in the low back.
You may, if you wanna use ultrasound
or you're gonna do some mobilizations
you'll put that in there.
And then you may, I didn't put it on here.
Short term goals to be met in one to two weeks,
long term goal to be met in four to six weeks.
- Very good.
- So there you go.
Soap has nothing to do with cleaning yourself
and all boils down to right here.
So if you're a student
and you want to be a soap master, here you go.
- You've come to the right place. Thanks a lot.