SOAP guide- Subjective, Objective, Assessment, Plan PDF

Preview

Summary

This material is summary of SOAP so take time so to read...

Description

SOAP INITIAL EVALUATION General Information Pt’s Name: Age: Sex: Address: Civil Status: Handedness: Occupation: Referring Unit: OPD or ____Ward Referring MD: Rehab MD: Date of Consultant: (OP)/ Admission (IP) Date of Referral: Date of Initial Evaluation: Diagnosis: SUBJECTIVE CHIEF COMPLAIN  Can state verbatim or translate  Note initial RPE if cardiac or pulmo pt. HIST HISTORY ORY OF PRESENT ILLNES ILLNESS S  Present condition started ___ days/works/months/years prior to PTIE (prior to initial evaluation……….  Pertinent questions to the patient in order to formulate your Initial evaluation 1. Why the pt. has come for help? -this is the problem or c/c 2. When did the problem start or how long has the problem existed? 3. Is there any inciting trauma? What happened? 4. Was the onset slow or sudden? 5. Where the sx that bothers the pt? -localized? -radiate? -unable to localize sx? 6. For Pain: a. what are the exact activities or movements that cause pain? -what aggravates/trigger the sx? -what relieves pain? -quantify pain – pain scale or min., mod., severe -type of quality of pain b. is the pain constant? Periodic? Episodic? Occasional?

- associated with the rest, activity, certain postures, visceral functions, time of day 7.For joint problems, ligaments, and menisci - does it exhibit locking, unlocking, twinges, instability? *For cases of cervical myelopathy: -has the patient experienced any bilateral cord symptoms, fainting, and drop attacks? 8. Dizziness/vertigo (synonymous but vertigo is more severe than dizziness) 9. What did you find about the problem? -self medication, hilot, ignored, etc. 10. What made patient seek medical advice? -what were done by the pt.? -X-rays, CT scans, MRI, Doopler US, ECG, EMG-NCV ect. -meds given NOTE: these data can be included under lab results and meds taken  Any condition in the past that may affect the present condition or treatment  Has the condition occurred before? Date?  Write “unremarkable” or “insignificant” if none Ex: HTN - controlled/ uncontrolled -since when? DM – type? -since when?  Hx of trauma relevant to case  Hx of major illness (write the date/hospital)  Hx of surgery relevant to case  Hx of allergies FMHX (F (FAMIL AMIL AMILY Y MEDICAL HIST HISTORY) ORY)  Anything in the family hx that maybe related to the condition at present  Write “unremarkable” or “insignificant” if none  HTN, DM, cardiac disease, cancer, AIDS, PTB, asthma, scoliosis, CP, etc.. (any case that has familial predisposition relevant to pt’s case) ANCILLIARY PROCEDURE/L PROCEDURE/LABORA ABORA ABORATORY TORY EXAMS  X-rays, CT scans, MRI, droopler US  Cythologic and bacteriologic tests  EMG-NCV, ECG, telemetry, oximetry, PFT’s, etc…. MEDICA MEDICATION TION T TAKEN AKEN (if significant) ENVIRONMENT ENVIRONMENTAL AL ASSESSMENT (only if applicable)  Type of house (bungalow type, etc..)  Note the presence os stairs, ramps, etc…  Height of steps, #of steps, amount of inclination for ramps, presence of railing

    

Distance between rooms How far is work from pt’s home Width of door/entrance Toilet seat height and presence of hand rail Type of floor (e.g.. non-skid vinyl)

HOME SITUA SITUATION/F TION/F TION/FAMIL AMIL AMILY Y SUPPORT/ECONOMIC BACKGROUND  Who lives with the pt. that takes care of the pt?  Is the pt. the head of the family?  Is the pt. financially capable of acquiring physical therapy services or continuing physical rehabilitation? Prior level of ffunction/Lifestyle unction/Lifestyle  Occupation  Lifestyle- sedentary/ active/ etc.  Smoker? -# of sticks per day x age -# of sticks per pack  Alcohol beverage drinker (note only if necessary) Patients Goals OBJECTIVE

VIT VITAL AL SIGNS  BP – mmHg  PR PR--bpm  RR RR--cpm  T-degrees celsius  HR HR--bpm OCULAR INS INSPECTION PECTION  Manner of presentation  Without assistance  Supervision: close guarding, contact guarding  With assist- level: min, mod, max (+ __ assist)  With assistive device-(type, amount of WB, type of appliance, laterality)  w/c stretcher, mother-borne, etc.  bed ridden, bed bound, bed fast  Level of consciousness- (alert, confused,lethargic, obtunded,stuporous, comatose)  Attitude of patient – apprehensive, restless, resentful, depressed  Body type- (mesomorph, ectomorph, endomorph)  Observe for all (+) findings then record in cephalo caudal manner (don’t forget the body part where it is observed nd the laterality)  Atrophy, swelling, hypertrophy  Gait deviations  Postural asymmetry

        

Bony deformities Wound/scar (new scar- red, old scar- white, hypertrophic or keloid) if not a wound case/ problem) – size, color, shape, depth, odor Callosities, blisters, inflamed bursa, sinuses Crepitus, Snapping, clicking sounds Other abnormal findings All attachments that you can find (indicate the laterality) IV line, ECG monitor and lead wires, NGT, T-tube, thoracostomy tube, O2 cannula, O2 mask, prosthesis, orthosis, cast, bandage, wound dressings Changes in in skin color (red- inflammation, bluish/cyanosis – perfusion) and condition (skin elasticity, shiny skin, hair loss, ecchymosis) if significant Note for all important (-) findings (pertinent to case)

PALPA ALPATION TION *(where ? laterality?) *choose only those that are significant  Feel variations in skin temp./tissue temp. -hypo-,hyper-,normothermic  Discriminate tissue tension -Tone (for neuro cases, include this under tone assessment) -ms spasm, ms guarding -distinguish between tissue texture e.g MPS, Fibrous bands or nodules  Identify bony deformities  Edema  Determine tissue tenderness- add grade of tenderness  Feel tremors and fasciculation  Feel dryness and excessive skin moisture  Crepitus – soft/fine – cartilage -course- bone -creaking/ leathery – tendon 

Amount of subluxation- measure in fingers – breadthing

Note Note: document all (+) 1st before sig (-) findings. If palpation will trigger Sx in pt., perform this test last during the evaluation ROM (RANGE OF MO MOTION) TION) Motions of (B) UE/LE, neck, trunk were assessed actively, pain free and are WNL except for the ff: (if there are maximum of 5 joints with LOM) Joint & AROM PROM N Difference End Feel Laterality OR Active ROM of (B) UE/LE, head,neck & trunk revealed findings that are WNL and pain free. The ff joints were assessed passively with the ff findings:

Joint & Laterality

PROM

N

Difference

End Feel

Sig: (take note of lecture on selective tissue tensions testing)  LOM 2° to pain on (B) active and passive maybe limited  LOM 2° to contracture (B) active and passive maybe limited  LOM 2° to tightness (usually active is limited but passive is normal or nearly (N)  LOM 2° to weakness (active is limited, passive is (N) MMT (MANUAL MUSCLE TESTING) Resisted isometric testing revealed of __(5/5 or 4/5) for the muscles of (B) UE/LE head and trunk (if with weakness, continue with……..) except for the following muscles wherein standard MMT was used.

Muscle

Grade

OR All major muscles of (B) UE/LE were grossly graded ______ (5/5 or 4/5 etc…) Note: -Break test was used -Resisted Isometric Testing Note: if you see these two for pain or contracture, no need to document using RANGE grade.  In cases of contracture or pain, using MMT will require documentation or range grade Note: available range/grade of muscles  For SCI, may use ASIA chart to document muscle strength  For UMNL, use FMT instead of MMT as heading (or in cases of extreme/severe pain)  Use NWB functional act for (B) UE  Use WB functional act for (B) LE (or upright motor control test for LE)  Use functional activities for trunk; reaching, lateral flexion, supine, prone  For children, use Pedia MMT or FMT Sig: Muscle Weakness 2° to -inactivity -immobilization -disuse -denervation -tendon/ms rupture SPECIAL TESTS  Use only those that will confirm the diagnosis and are significant to the case. It is not our duty to rule out diagnosis; can only be use to confirm a difficult diagnosis  Significance: Give significance for each test that you have used  Every test has a corresponding significance or use NEURO EVA EVALUA LUA LUATION TION

Sensory T Testing esting - If not neuro cases, separate using testing or any if necessary A.Superficial Sensation - Note for the STD’s used (pin prick for pain, brush for light touch and thumb for pressure) - Pt. has intact sensation as to pain, light, touch and pressure - Pt has ____% sensory deficit as to ____(sensation) on where - For affectation of peripheral or cutaneous innervations, test isolated area supplied by the nerve - Documentation for dermatomal /cutaneous distribution , testing, may draw past tested & or isolated distribution of nerve Significance: -Hyperesthesia/ Hypoesthesia 2° to affectation? ____nerve _____dermatome Brodman area 3,2,1 Thalamus ALTS -Hyperesthesia 2° to pain - note weather distal or proximal part of body has been assessed B. Deep Sensation -assess for movement and position sense -intact proprioception on (B) UE/LE -note that this is tested using distal body parts C. Cortical Sensation -perform stereognosis (if cannot manipulate with hands, use graphesthesia) -tactile localization, 2pt. discrimination, bilateral simultaneous stimulation -you can use the ff terms: Intact, Decreased, Exaggerate, Inaccurate, Absent,Inconsistent, Ambiguous MSR MSR’s ’s -for neuro case, for ortho cases with affectation of nerve roots or peripheral innervations Legend: 0 areflexia 1+Hyporeflexia 2+Normoreflexia 3+Hypereflexia 4+Clonus

TON TONE E ASSES ASSESSME SME SMENT NT - Use terms: hypo; hyper; normo-tonic and the laterality and limb tested - E.g (+) gr.1 spasticity on (B) LE (Ashworth Scale) - Sig: spasticity 2° to ____ - Rigidity 2° to ____ - Dystonia 2° to _____

-

Paratonia 2° to ____ Flaccidity 2° to ____

Clinical Rating Scale used to assess tone: 0-no response (flaccidity) 1+decreased response (hypotonia) 2+normal response 3+exaggerated response (mild to moderate hypertonia) 4+sustained responses (severe hypertonia) MODIFIED ASHWOR ASHWORTH TH SCALE SCALE- for spasticity grading GRADE 0

DESCRIPTION No muscle tone

1

Slight in muscle tone manifested by a catch & release or by minimal resistance at the end of the ROM when the affected parts is moved OR Slight in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM More marked increase in muscle tone through most of the ROM, but affected parts easily moved Considerable increased in muscle tone, passive movement difficult Affected part rigid in flexion and extension

1+ 2 3 4

CRANIAL NERVE TESTING Cranial Nerv Nerves es I II

Result of the Test Pt. can smell Intact light reflex

III,IV,VI V VII VIII IX,X XI XII

Intact conjugate eye movement Intact corneal Reflex/facial expression Functional muscles of facial expression Pt. can hear Intact gag reflex Normal trapezius/ SCM strength Pt. has (N) articulation

Sig: of affected, usually signifies brainstem affectation or individual cranial nerve is affected, may manifest as central or peripheral lesion. Pathological R Reflexes eflexes -e.g (+) clonus on ® LE -sig. hyperactive stretch reflexes -(+) Babinski ( some book suggest a (+) or (-) extensor plantar response instead of Babinski -sig. corticospinal tract affectation or UMNL

Developmental R Reflexes eflexes -Test 4 levels of reflex development -e.g (-) grasp ferlex on (B) feet and hands -(+)ATNR -(-) protective extension in sitting -sig.Pt. is in brainstem level of reflex development Coordination T Testing esting  Non Equilibrium TEST Finger to Finger Pronation/Supinatio n

(L) 4 4

(R) 4 4

4

4

Hand Tapping *Select test appropriate for Pt. & case  Equilibrium Wound Assessment -shape -size -depth -odor -color- scar, granulation, tissue -if pressure sore, note the grade Pressure Sore Gr Grading ading Grade 1: Discolouration of intact skin not affected by light finger pressure (non-blanching erythema) This may be difficult to identify in darkly pigmented skin Grade 2: Partial Thickness skin loss or damage involving epidermis and/or dermis. The pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater Grade 3: Full thickness skin loss involving damage of subcutaneous tissue but not extending to the underlying fascia. The pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue Grade 4: Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue Stump Assessment -shape, length, type, calculate% of stump to classify -Type of closure used (fish mouth or post flap) -Is skin mobile or adherent tissues -Presence of neuroma Electrodiagnosis...