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9 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Elements of a SOAP note
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S: Subjective
O: Objective A: Assessment P: Plan |
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Subjective
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Client's report/perceptions of the problem, which are documented as a quotation: "Client stated..."
-Use something significant the client says about his treatment or condition, or a caregiver says |
Client reports about problems, complaints, life circumstances, goals, current performance, limitations
Can be verbal or non-verbal "QUOTE" |
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Objective
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Observation, consists of factual or professional information that is confirmed or validated by therapist
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Objective elements
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*begin this section with length of time
*Report what you see chronologically *Focus on performance elements. i.e, client worked on tripod using pegs *Specify the part of the task the assistance was used for when giving assist levels. i.e., Client min assist for correct hand placement during pivot transfer to toilet *Show skilled OT happening, don't just list all the assist levels *Write from the client's point of view, leaving yourself out *FOCUS on the client's response, rather than what you did. *Avoid being judgmental |
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Assessment
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Directly related to the subjective and objective sections. Therapist's professional opinion and analysis are documented. Clarification of client's goals and problems and therapist's ratings of client progress
*Patient deficits *Patient strengths *Patient level of motivation *Every "A" must have evidence in "O" statement *No new information, just a summary |
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Plan
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Specifies the type, frequency, and duration of interventions to use in next session and or response to progress or lack of. Updated goals, discharge plans, and home programs. i.e., Continue tx one hour daily for 2 weeks
*Identify the specific performance areas that will be addressed during that time: Client to continue OT one hour daily for 2 weeks for instruction in I bathing, grooming, and hygiene. *End with a LTG or STG, whichever is more appropriate for your client and the practice setting: By the end of the week, client will be able to don socks I sitting at the EOB without losing balance. |
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Discharge Summary
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*When?
*Achieves goals *D/C from facility *Refuses/ceases to come to therapy *Maximum benefit |
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OT determines discharge
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*Prepares, documents and implements dc plan
*MEDICARE B outpatient requires DC note *MEDICARE A inpatient dc follows facilities policy for DC |
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Guidelines for DC note
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*Start and end of services
*Frequency/# of sessions *Summary of intervention *OT outcomes *Initial and ending status *Recommendations of OT |
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