Chapter 13: The SOAP Note: Stating the Problem

Introduction

The Problem or Diagnosis is the first section of the SOAP Note. While learning how to write in the SOAP Note format, you will notice you are using the same information that you used to write in the Patient/Client Management Note format. However, in the SOAP Note format you are organizing according to the source of the information instead of the type of information as you did in the Patient Management Note format. The American Physical Therapy Association has expressed a concern that many therapists have developed bad habits using the SOAP format.¹ Either note format can represent best practice in documentation as long as the components of the patient management model are represented.

In many facilities, the major problem or problems that have brought the patient to you for treatment are stated prior to actually beginning the SOAP Note itself. This is usually stated as the Problem or Diagnosis. The Problem part of the note can be stated as the patient's chief concern. It may be medical, psychological, or functional.

In some facilities, the pertinent history or medical information taken from the health record is included in the Problem area. In others, information from the health record is the first information written in the Objective part of the note. For the purposes of this textbook, you are expected to state the patient's pertinent history or medical information from the health record information in the Problem area of the note, because it is not the result of your examination (your interview or hands-on tests and measures you have conducted).

Information that follows may be included in the Problem part of a SOAP Note.

• Demographic information about the patient, known as identifying information. This information can include the patient's name, address, admission date, date of birth, biological sex, dominant hand, race, ethnicity, primary language spoken, education level, advance directive preferences, referral source, and reasons for referral to therapy such as medical diagnosis.

• Current conditions/diseases affecting the present condition or treatment (e.g., hypertension, CHF).

• Recent or past surgeries affecting the present condition or treatment (e.g., hx of ® TKA performed on [date]).

• Past medical history affecting the present condition or treatment (e.g., hx of ® hemisphere stroke in March 2014 c̄ residual Ⓛ hemiparesis).

• Medical test results affecting the present condition or treatment (e.g., x-ray reveals fx Ⓛ tibial plateau).

• Patient medications currently being taken by the patient if your source of information regarding patient medications is from the health record and not the patient.

There are no worksheets for this chapter. As you practice writing notes on the worksheets on the S (Subjective) part ...