SOAP note template PDF

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Description

Documentation Template- Best suited to acute hospital placement Physiotherapy sticker + Date/time

Initial assessment only HOPC

Brief history of presenting condition + other relevant events in course of admission If post-op → How many days post-op, surgeon orders

Relevant PMHx E.g. OA knee, IHD, T2DM

Co-morbidities Respiratory history → conditions (e.g. COPD), smoking history (pack years), home oxygen, medication, pulmonary rehab in past 12/12. Baseline for resp. Symptoms e.g. usual amount/colour of sputum

SHx

Patient lives alone or with somebody Type of accommodation List of services used + frequency e.g. {PCA, HH, MOW)

Home Steps at access setup/environme nt Rails/aids in shower or toilet PMLOF/PMM

Bed mobility (Assistance) Transfers Indoor/outdoor mobility (aids?) Ex tol → limiting factor/s Falls → 12/12, circumstances of fall, injuries acquired, ability to get off ground Personal/PADLs → showering, dressing, meds, eating etc. Domestic/DADLs → cooking, cleaning, laundry etc. Community/CADLs → shopping, employment

All notes Initial Ax or r/v, 3 point ID check, informed consent Subjective Note: can use “as per pt”

Anything reported by patient → pain, SOB, dizziness, nausea, vomiting, cough, sputum, wheeze, feeling anything on chest to clear, ease of mobilising, how far mobilised etc. Anything from nursing staff Sometimes may be appropriate to put goals in subjective

Objective

Patient’s position → SOOB, LIB

Include any other objective measures relevant to stream e.g. vision testing, spasticity etc.

LOC → drowsy, alert, orientated to TPP Obs → state abnormal obs from charts, if not state that obs stable as per charts CxR → put date of x-ray and main findings ABGs → time taken/FiO2 at time → pH, pCO2, pO2, HCO3 & BE Haematology → Hb, WCC, platelets if abnormal Biochemistry (if relevant) → CRP, troponin/CKMB (cardiac), Urea/GFR (renal), Bilirubin (liver), creatine (skeletal muscle) Attachments → CVC, IV, Wound drains, NGT (naso-gastric tube), IDC (catheter), PCA, Epidural, ICC Respiratory → Breathing pattern and WOB (if abnormal), Bibasal expansion (normal, reduced or symmetrical), chest auscultation (breath sounds and added sounds), Sputum (colour, consistency, amount), cough (dry/moist, productive/non-productive) Muscle power screened grossly + documented for patients RIB for prolonged periods before physio initial contact, patients on epidural, or if unsure. Sensations screened and documented if epidural (dermatomal) → can use a table here if appropriate. Mobility Bed mobility → level of assistance, aid used Transfers → lie to sit, sit to stand, bed to chair → level of assistance, aid used, movement pattern if abnormal Ambulation → level of assistance/ aid used/distance/gait pattern/ Additional balance measures (e.g. CTSIB) or other objective measurements of mobility e.g. TUG, falls risk Ax

Action

Usually can write “Ax a/a” and use // and then summarise Ax findings List all treatment done including position, dosage etc. Include any discussions with patient and education/ Use // to show re-assessment for example “pt. Improved ROM to 90°” or “pt. Tolerated well”. Analysis → How the Rx went e.g. patient tolerated, chest productive, mobilised well, patient participated well **Can also give reasoning for Rx if necessary**

Plan

PT plan → goals, “ongoing r/v to…” **be specific with plan, but do not specify definite date as this is legally binding** N/s instructions → e.g. pt to mobilise with SPS with s/v, with 4WF independently D/c plan → e.g.not safe for discharge from PT perspective as mobility...