Chapter 15: The SOAP Note: Writing Objective (O)

Introduction

The Objective (O) part of the note is the section where the results of tests and measures performed and the therapist's objective observations of the patient are recorded. Objective data are the measurable or observable pieces of information used to formulate the Plan of Care. Good tests and measures that produce objective data are also repeatable, valid, and reliable, allowing for comparison of data over the course of treatment to document patient progress. The therapist's objective observations, tests, and measures thus serve as comparative data as the patient's progress is monitored and re-evaluated.^1,2

The actual content of the Objective section of the SOAP Note consists of two sections that are the same as the Systems Review and Tests and Measures sections of the Patient/Client Management Note. The content for both note forms includes the results of the Systems Review, preferably using a form, and the tests and measures performed by the therapist and the therapist's observations. Consequently, much of the information presented in this chapter is similar to that presented in Chapter 12. A main difference between the two formats is that the Objective section of the SOAP Note is divided into two major sections: Systems Review and Tests and Measures.

The Systems Review

The Systems Review is a limited set of tests and measures that examine briefly the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems, and the patient's communication, affect, cognition, learning style, and education needs. The Systems Review is the beginning of the hands-on part of the examination. Some information gathered in the Systems Review may be integrated into the data recorded in the Tests and Measures subsection under Objective, or recorded on a form either manually or electronically. For the purposes of this textbook, you are to record the information on a form. Whenever you record information on a form, you should refer to that form in the Objective part of the note.

The Systems Review should include the following information:

• Cardiovascular/pulmonary system: all completed in a resting state: heart rate, respiratory rate, blood pressure, presence of edema

• Integumentary system: skin pliability or texture, skin integrity, scars, skin color

• Musculoskeletal system: gross symmetry during standing, sitting, and activities; gross range of motion; gross strength; height and weight

• Neuromuscular system: gross coordinated movement (balance, gait, locomotion, transfers, transitions), gross motor function (motor control, motor learning)

• Communication and language: the ability to make needs known

• Affect: the patient responds with expected emotional/behavioral responses

• Cognition: consciousness, orientation to person, place, and time

• Learning style: learning preferences (listening, reading, pictures, demonstration, other), learning barriers, and education needs

Figure 15-1 is an example of a form that can be used to record Systems Review. The Systems Review is also used to plan the rest ...