SOAP Notes

SOAP notes are what physical and occupational therapists call their daily notes.  I don’t know if that’s what speech therapists call their notes.  Every time you have a PT or OT appointment, the therapist will write a SOAP note.  I don’t know if this information can be helpful in any way but here ya go.  SOAP is an acronym for subjective, objective, assessment, plan.  The subjective is whatever you say.  So if I go into my OT appointment and say “I’m still writing really crappy,”  she’ll write on her note “patient reports she is still writing crappy.”  She’ll use the word ‘crappy.’  It’s whatever the patient says.  I remember one time I wrote patient reports “I feel like Superman.”  That boosted my ego a bit.  Objective means whatever you did during the session.  So when I’m in OT and put the pennies in the piggy bank 3 times, she’ll write that down – that I did that 3 times.  It’s whatever you do during the session.  Assessment is weird.  It’s supposed to be how the patient did during the session but often it ends up being objective.  A good assessment would be “due to decreased strength, the patient had trouble standing up today.”  This is an assessment of the situation.  Much better than “the patient had trouble standing up today.”  That’s objective.  Then plan is what you plan on doing next session.  If you plan on adding an exercise, you write “add leg press” or whatever.  If you plan on doing a re-evaluation, the therapist would write “do re-eval.”  Ok that’s SOAP notes for you.

Categories: Rehab

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2 replies

  1. Doctors do SOAP notes too. Subjective is the same…patient’s own words. Objective is vital signs and physical exam as well as any lab results, imaging, etc. Assessment has to have a specific diagnosis (“CVA” or “VAD” for example). Plan is the plan. “INR today. Continue PT/OT. Due for repeat MRI/MRA. Follow up in 4 weeks.”
    That said, with the advent of EMRs, most doctors automatically do an “H&P” instead every time. You take a SOAP note and flesh it out with social history (“no etoh, no cigs, married, two kids”), past medical history (“hypothyroidism, on replacement”), past surgical history (“tonsils age 16”), medications and doses, allergies, and ROS (review of systems/symptoms…basically, a more detailed review of symptoms someone is or is not having)…ta-da you have an H&P and can bill more for the same visit. The EMRs automatically carry over the social, medical, and surgical history from the previous visit and theoretically someone is checking your medications and allergies at every visit. If you are given a checklist of symptoms when you check in at your doctor’s office, that is the ROS for the H&P that is created about your visit.

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