BP #4 - SOAP Note

On this day in class, we talked a lot about documentation. The common way to document a clinic note is called a SOAP note. This stand for S- Subjective, O- Objective, A- Assessment, P- Plan. In the subjective part, this is where you put information reported to you by the client. This could be a direct quote coming from the client's mouth, or a statement summarized that the client reported to you, such as "I didn't sleep much last night due to pain in my left arm." In the objective part of the note, this is where you state clinical findings and measurable objective data such as, client participated in Dynavision activities to increase trunk balance and UE functional mobility Client was able to achieve score of 85% with minimal cueing or assistance. In the assessment section, this is where you put your judgment and opinion as the practitioner. This is your interpretation of the S and O such as, client has demonstrated increase in UE functional mobility and trunk balance since last assessed a month ago. The plan section is where you state their intended future plan for treatment such as continue with POC or d/c to HEP. You either modify or continue the POC here.