How to write SOAP notes?

Answer 1

Subjective: 1. What happened 2. Where is the location of pain 3. Abnormal sounds/sensations 4. Equipment/ weather 5. Previous history

Objective: 1. Swelling 2. Discoloration 3. Deformities 4. Compare bilaterally 5. Circulation 6. Nerves 7.Palpate- a) bones b) ligaments c) muscle/tendons d) misc. 8. Range of motion- a) active b) passive c)resistive 9. Fracture tests- a)tap b) tuning fork c)parallel bone compression d) visual 10. Muscle test- a) resisted r.o.m. b)break test c) special test 11. Stress test ligament 12. Miscellaneous

Answer 2

SOAP notes stand for Subjective, Objective, Assessment, and Plan. In the Subjective section, you document the client's details and their subjective complaints. The Objective section includes measurable data like vitals or physical exam findings. The Assessment section is where you provide your diagnosis or assessment of the client's condition. Finally, the Plan section outlines the next steps, such as treatment options or follow-up appointments. Make sure to organize your notes in a clear and structured manner for easy reference.