Assessment and Plan of Care: SOAP Notes

Writing Patient Centered Functional Goals:

 Ask:
 “What are some activities that you want to do, but this problem
keeps you from doing?”
 “What did you do before that you cannot do now that you have this
problem?”
 “What activities do you need help to perform that you would rather
do yourself?”
 “What are your concerns about returning to work, home, school, or
leisure activities?”

Functional Pt Goals
 How can I help you to be more independent?
 Imagine it’s 6 months down the road. What would you like to be
different about your current situation? What would you like to be
the same?
 If you were to focus your energies on one thing for yourself, what
would it be?

Interview Questions to Help Find Functional Goals

 Tell me about yourself.
 Tell me about your home life. What activities do you do at home?
 Tell me about your work activities.
 What do you like to do in your spare time?
 Describe a typical day for “you”.

Writing the Pt Centered Functional Goal

 WHO (Audience)
 WILL DO WHAT (Behavior)
 UNDER WHAT CONDITIONS (Condition)
  HOW WELL ( Degree)
 FUNCTION
 BY WHEN (Time Line)

Functional Goals
 “Who”: always the patient. If dealing with child, still focus on the
child. Not “parent transferring the child, but transferring with
assistance from parent.”
 “What”: the activity the patient will perform. Ex: type on keyboard,
mop floors, don’t say “clean house”-be specific.
 Functional Goals
 Under What Conditions
 Incorporate specific elements of a measure into the goal: measure of
distance, time to perform activity.
 Make it relevant- gaining 45/ of shoulder ER is not always required to
comb hair
 Ex: across uneven surfaces, down 5 steps
 Functional Goals
 HOW WELL?
 Amount of assistance required from other people for pt to perform
activity, may also include details of number of successful attempts to
perform activity.
 EX: verbal cues every 30-45 secs., dress within 7 minutes while
standing next to chair for balance.

EXAMPLE of Functional Goals

 Pt will walk 15 ft. from bed to bathroom with standard walker,
WBAT on RLE, with SBA of 1 for potential loss of balance by
_______.
 Pt will dress in 10 min., using stable chair to sit on or for standing
balance by ________.
 Pt will walk 200ft. to/from mailbox, modified independent with
straight cane down 5 steps on front porch by ________
 Pt will weed flower beds, moving from kneeling to standing as
needed and no loss of balance, x 30 min. by _________
 ASSESSMENT
* INTERPRETATION of the “S” and “O”
* I. Problem List
* Prioritize problems from most important to least important.
* List areas that are not WNL
* Include functional limitations as problems (ex: restricted work)
* PARAGRAPH Summary-
“Tell the story”
* This 85yo F displays significant reduction in R shldr ROM, lacks
R shldr strength, and has moderate changes in her posture,
which limit 1) her ability to reach into cabinets for plates, 2) her
ability to dress and fasten bra, and 3) driving safely, as she
cannot use her R arm for turning. She is also a diabetic and was
a previous smoker, with contributes to slower healing rate. Due
to these impairments and limitations, she is a good candidate
for skilled Physical Therapy intervention. Therapy may be needed
for an extended time due to her health concerns.
 ASSESSMENT (cont)
* II. Short Term Goals (Building Blocks)
* Guide immediate care plan
* Objective, realistic, measurable
* Based on LTG
* Briefer Time Period than LTG’s
* Involves professional judgment
* Functional Based
 ASSESSMENT (cont)
* III. Long Term Goals (Final Outcomes)
* Guides total length of time pt in therapy
 * Objective, realistic, measurable
* Based on functional goals
* Involves professional judgment
* ASSESSMENT (cont)
* IV. SUMMARY- contains analysis of plans and goals for pt. May include:
* Tell the story
* Inconsistencies
* Justification of goals
* Discussion of pt.’s progress
* Discuss limitations of progress( multiple co-morbities)
* Pt.’s rehab potential
* ASSESSMENT-Summary (cont)
* Discussion of difficulty obtaining info
* Suggestion of further treatment needed
* Physical therapy diagnosis
* Misc.
 PLAN
* Frequency (how often: 1-2-3-4-5x wk)
* Duration (how long: 1x, 1 wk, 2 wks, etc.)
* Treatment (what are you going to do as a professional that makes
a difference in this individual)
* PLAN
* Location of treatment
* Treatment progression/reason you are doing trx
* Plans for further assessment/ reassessment
* Plans for DC
* Pt. and Family Education
* Equipment needs
* Referral to other services
* PLAN : PROGRESS NOTES
* Note changes in plan in progress notes
* Notes continued treatment plan in progress notes
* PLAN DC NOTES
* Review treatment
* Review HEP
* Review any other instruction
* Equipment sold
* Referrals made
* Review of attendance-Consistent, # of times, missed trx
* PLAN DC NOTES
* Where Pt DC’d to
* Reason for DC
* Recommendations for followup care
 SUMMARY
 EVAL on every pt: includes
 S: Med history, subjective comments, their functional goals
 O: Objective findings: YOUR evaluation
 A: Assessment: Problem List, STG, LTG, summary of condition,
home instructions given,
 P: Frequency, duration, plan
 Redneck medical terms
 READY TO DO YOUR FIRST NOTE?
 Please write your evaluation on your first patient(your partner)