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Examination:
This includes information obtained from history, review of systems, PT diagnosti
c tests and measurements.
Diagnosis
Here, the level of impairment, activity or mobility and any participation restri
ction is indicated as determined by the physical therapist.
Prognosis
This part may include documentation of the predicted level of improvement (goals
) that may be attained through the proposed treatment interventions. It also inc
ludes the duration or amount of time required to reach those goals. Prognosis do
cumentation is usually included in the plan of care and is not necessarily a sep
arate document. (See plan of care below)
Plan of Care
The plan of care of the initial evaluation or examination is usually stated in g
eneral terms. It includes the goals, which are stated in measurable terms; plann
ed treatment interventions; proposed frequency and duration of therapy required
to attain the goals; and discharge plans as determined by the therapist.
Information in physical therapy notes may include patient status or self-report;
a description of interventions provided including frequency, intensity, time, a
nd duration; and communication among providers. Documentation may also include s
pecific plans for the next visit or visits.
The physical therapy notes (PT Notes) is a particular format of recording inform
ation employed by physical therapists. Most PT notes are written in the S.O.A.P
note format, which stands for Subjective, Objective, Assessment and Plan. It is
a record of the progress of the patient, which is included in his or her patient
chart.
SOAP Notes Parts
Subjective
The information contained in the subjective part of the PT note includes what th
e patients says about his or her condition or problem. It can be in the form of
a quote from the patient's statement, for example, "My back is so painful, espec
ially after sitting for many hours at work."
It is better to look for subjective information that is more specific, such as "
My back pain has reduced from 10 to 6." Or it can be stated as "Patient states t
hat his back pain has reduced from pain level of 10 to 6."
It is important that in this section, the subjective information should be relat
ed to the patient's condition, progress in rehabilitation, functional mobility o
r quality of life. Other irrelevant information should be excluded, such as "Bri
ttney's bald again."
Objective
This section of the PT note is where concrete measurements, such as blood pressu
re and range of motion and treatment interventions performed are recorded. This
section should include specific treatments. It should also include the frequency
, duration and equipment used.
The objective section should be specific enough so that in case the therapist is
not available, another therapist can treat the patient.
Assessment
This is where the impression of the physical therapist is recorded regarding the
patient's performance during the treatment procedure. "The patient tolerated th
e treatment well" statement is commonly used, but it's not telling whether or no
t the client is progressing throughout the overall treatment plan.
Plan
This is the final section of the physical therapy note. It is where the physical
therapists would outline the course of treatment after considering the informat
ion he or she has gathered during the treatment session. If the therapist would
like to continue treatment following the original plan of the care, the PT might
just say "Continue with current plan."
Writing physical therapy SOAP notes is an invaluable documentation that every ph
ysical therapy student should learn. Students learning how to write SOAP notes a
lso need to learn how to write physical therapy abbreviations.
Just like other medical documentations, every patient encounter should include t
he following components:
the patient’s full name. Identification number is included, as well, if applicable
.
the full name of the healthcare provider and proper designation (e.g. PT, DPT, M
PT) including date of treatment and authentication (e.g. manual or secure electr
onic signature).
SOAP (subjective, objective, assessment/analysis, and plan)
Subjective
This should include what the patient has to say about his/her current condition.
For example, “Pain in my lower back has improved” or “I had a good night’s sleep last n
ight following the treatment session we had yesterday.”
The more specific the subjective statement is, the better the PT can follow up o
n specific therapy care. For example, “Pain on my back decreased to scale of 5 fro
m a pain scale of 10.”
Objective
The objective element of documentation includes all the pertinent measurements o
btained from the patient including vital signs (e.g. blood pressure, temperature
, respiratory rate), range of motion (ROM) measurements, muscle testing measurem
ents, etc.
Also, specific treatment or interventions are written here. The equipment provid
ed, number of repetitions, intensity, and duration should be included whenever a
ppropriate. For example:
PROM (passive range of motion) exercise on ® elbow, 3 sets, 10 repetitions, full R
OM (range of motion)
® Knee extension, 3 sets, 10 repetitions, 5 lb. ankle weight, full ROM
This part of the SOAP note should be specific enough so that when the treating p
hysical therapist is out for the day, another PT can pick up and treat the patie
nt.
Assessment/Analysis
This section of the SOAP note includes the impression coming from the therapist
regarding the patient’s current situation since the last visit or treatment. It ma
y also include the perspective of the PT whether the treatment plan will be cont
inued or modified.
Example: “The patient tolerated the exercises well but patient required frequent v
erbal cues from the physical therapist to complete the exercises at full range.”
Plan
This is where the physical therapist writes the plans for the patient’s next visit
, which may include the objectives, interventions/treatments, progression parame
ters, and precautions.
Example SOAP Plan: “Continue with therapeutic exercise program. Caution – patient ne
eds frequent verbal cuing to complete exercises at full range.”
S = “Pain on my back has improved from pain scale of 7/10 to 3/10.”
O =
VS:
BP = 120/80 mmHg
RR = 12 cpm
PR = 80 bpm
To = 37o
Treatments provided:
1) Hot pack on lumbar area x 20 min. in prone.
2) Deep kneading massage on lumbar paraspinal muscles x 5 min. in prone.
3) Ice pack on lumbar area x 20 min. in prone.
4) Prone lumbar extensions x 20 reps.
5) Educated patient on:
a. Proper lifting techniques with 10 lb. box lift x 20 reps.
b. Proper sleeping techniques with emphasis on maintaining normal lumbar curve.
A = Patient tolerated treatment well and appears to be compliant with home exerc
ise program.
P = Continue with current treatment plan. Caution – patient needs frequent verbal
cuing with proper lifting techniques.
The SOAP note should, of course, include basic information, such as the name of
the patient; referring physician or doctor; date of treatment; and the name and
designation of the physical therapist who provided the services. Signature, eith
er manual or electronic, should also be included.
Parts of the SOAP Note
SOAP notes writing is divided into several parts:
The Subjective part is where patient information is written including history of
present illness (HPI), past medical history, and family medical history.
Written on the Objective part of the SOAP are tests and measurements done on cli
ent/patient, which includes vital signs, range of motion (ROM) measurements, PT
special tests, muscle tests, among others.
Informations entered in the physical therapy SOAP Assessment section include lis
t of client problems, goals (Short and Long-term goals) and physical therapist s
impression or summary.
The Plan part includes details on the course of treatment that would address the
problems listed in the assessment area of the SOAP note.
A
@ – at
ā – before
A: – assessment
AAA – abdominal aortic aneurysm
AAROM – active assistive range of motion
Abd. or abd. – abduction
ABG – arterial blood gas
ABI – acquired brain injury
ac – before meals
AC – acromioclavicular
ACL – anterior cruciate ligament
ACTH – adrenocorticotropic hormone
Add. or add. – adduction
ADL’s or ADL – activities of daily living
ad lib – at discretion
adm – admission/admitted
AE – above elbow
afib – atrial fibrillation
AFO – ankle foot orthosis
AIDS – acquired immune deficiency syndrome
AIIS – anterior inferior iliac spine
AJ – ankle jerk
AK – above knee
AKA – above knee amputee, above knee amputation
ALS – amyotrophic lateral sclerosis
a.m. – morning
AMA – against medical advice
amb – ambulate, ambulates, ambulated, ambulatory, ambulation
ANS – autonomic nervous system
Ant. – anterior
AP – anterior-posterior
approx. – approximately (also “~” symbol can be used)
ARDS – adult respiratory distress syndrome
ARF – acute renal failure
AROM – active range of motion
AROME - active range of motion exercise/s
ASA – aspirin
ASAP or asap – as soon as possible
ASCVD – arteriosclerotic cardiovascular disease
ASHD – arteriosclerotic heart disease
ASIS – anterior superior iliac spine
Assist. – assistive, assistance
A-V – arteriovenous
AVM – arteriovenous malformation
B
B/S – bedside
BE – below elbow
bed mob. – bed mobility
BID or bid – twice a day
bilat – bilateral (a B enclosed within a circle may also be used)
BK – below knee
BKA – below knee amputee, below knee amputation
BM – bowel movement
BOS – base of support
BP – blood pressure
bpm – beats per minute
BR – bedrest
BRP – bathroom privileges
BS – breath sounds/bowel sounds
BLE – both lower extremities
BUE – both upper extremities
BUN – blood urea nitrogen
C
_
c - with
C&S – culture and sensitivity
c/o – complains of
CA – cancer, carcinoma
CABG – coronary artery bypass graft
CAD – coronary artery disease
CAT – computerized axial tomography
CBC – complete blood count
C/C – chief complaint
cc. – cubic centimeter
cerv. - cervical
CF – cystic fibrosis
CHF – congestive heart failure
CHI – closed head injury
CKD – chronic kidney disease
cm. – centimeter
CMV – cytomegalovirus
CNS – central nervous system
CO – cardiac output
CO2 – carbon dioxide
Cont. or cont. – continue
COPD – chronic obstructive pulmonary disease
COTA – certified occupational therapist assistant
CP – cerebral palsy
CPAP – continuous positive airway pressure
CPR – cardiopulmonary resuscitation
CRF – chronic renal failure
CSF – cerebrospinal fluid
CV – cardiovascular
CVD – cardiovascular disease
CWI – crutch walking instructions
CXR – chest x-ray
Cysto – cystoscopic examination
D
D/C – discontinue, discontinued, discharge, discharged
dept. – department
DF - dorsiflexion
DIP – distal interphalangeal
DJD – degenerative joint disease
DM – diabetes mellitus
DNR – do not resuscitate
DO – doctor of osteopathy
DOB – date of birth
DOE – dyspnea on exertion
DTR – deep tendon reflex
DVT – deep vein thrombosis
Dx – diagnosis
E
ECF – extended care facility (In Physiology – extracellular fluid)
ECG/EKG – electrocardiogram, electrocardiograph
ED – emergency department
EEG – electroencephalogram, electroencephalograph
EENT – ear, eyes, nose, throat
EMG – electromyogram, electromyography, electromyography
ER or Ext. rot. – external rotation
E.R. – emergency room
eval. – evaluation
Ex. – exercise
ext. – extension
F
FBS – fasting blood sugar
FEV – forced expiratory volume
FH – family history
flex. – flexion
FRC – functional residual capacity
FUO – fever unknown origin
FVC – forced vital capacity
FWB – full weight bearing
Fx., fx – fracture
G
GB – gall bladder
GCS – Glasgow coma scale
GI – gastrointestinal
GIT – gastrointestinal tract
GSW – gunshot wound
GYN – gynecology
H
H/A - headache
H&H, H/H – hematocrit and hemoglobin
Hct – hematocrit
HEENT – head, ear, eyes, nose, throat
Hemi. – hemiplegia, hemiparesis
HEP – home exercise program
Hgb – hemoglobin
HIV – human immunodeficiency virus
HKAFO – hip knee ankle foot orthosis
HNP – herniated nucleus pulposus
h/o – history of
HOB – head of bed
HR – heart rate
hr. - hour
hs – at bedtime
HTN or Htn – hypertension
Hx – history
I
I&O – intake and output
IADL – instrumental activities of daily living
ICU – intensive care unit
IDDM – insulin dependent diabetes mellitus
IE – initial evaluation
IFC – interferential current
IM – intramuscular
imp. – impression
indep – independent
inf. – inferior
inv. - inversion
IR or int. rot. – internal rotation
IRDS – infant respiratory distress syndrome
IS – incentive spirometer, incentive spirometry
IV – intravenous
K
KAFO – knee ankle foot orthosis
kcal – kilocalories
KJ – knee jerk
KUB – kidney, ureter, bladder
L
L within a circle – left
Lat – lateral
LBBB – left bundle branch block
LBP – low back pain
LE – lower extremity
LOC – loss of consciousness, level of consciousness
LMN – lower motor neuron
LMNL – lower motor neuron lesion
LOS – length of stay
LP – lumbar puncture
LLQ – left lower quadrant
LQ – lower quadrant
LTG – long term goal
LUQ – left upper quadrant
M
MAP – mean arterial pressure
max. – maximal
MD – medical doctor, doctor of medicine
MED – minimal erythemal dose
Meds. – medications
MI – myocardial infarction
min – minimal
min. – minute
mm. - muscle
MMT – manual muscle test, manual muscle testing
mod. – moderate
MP – metacarpophalangeal
MRSA – methicilin resistant staphylococcus virus
MS – multiple sclerosis
MVA – motor vehicle accident
N
NDT – neurodevelopmental treatment
neg. – negative
NG or ng – nasogastric
N.H. – nursing home
NIDDM – non-insulin dependent diabetes mellitus
nn. – nerve
noc – night, at night
NPO or npo – nothing by mouth
NSR – normal sinus rhythm
NWB – non-weight bearing
O
O: - objective
OA – osteoarthritis
OB – obstetrics
OBS – organic brain syndrome
od – once daily
OOB – out of bed
O.P. – outpatient
O.R. – operating room
ORIF – open reduction, internal fixation
OT – occupational therapist/therapy
OTR – registered occupational therapist
P
_
p – after
P – poor (used in muscle testing)
P: - plan
P.A. – physician’s assistant
PA – posterior/anterior
para – paraplegia
pc – after meals
PCL – posterior cruciate ligament
PE – pulmonary embolus
PEEP – positive end expiratory pressure
per – by/through
PF – plantar flexion
p.o. – by mouth (per orem)
PERRLA – pupils equal, round, reactive to light and accommodation
P.H. – past history
p.m. – afternoon
PMH – past medical history
PNF – proprioceptive neuromuscular facilitation
PNI – peripheral nerve injury
POMR – problem-oriented medical record
pos. - positive
poss – possible
post. – posterior
post-op – after surgery
PRE – progressive resistive exercise
pre-op – before operation
Prep. – preparation
prn – whenever necessary
PROM – passive range of motion
PROME – passive range of motion exercise
PSIS – posterior superior iliac spine
PT – physical therapy/ therapist
PT – prothrombin time
Pt. or pt. – patient
PTA – prior to admission
PTA – physical therapist assistant
PTB – patellar tendon bearing
PVD – peripheral vascular disease
PWB – partial weight bearing
Q
q – every
qd – everyday
qh – ever hour
qid – four times a day
qn – every night
R
® - right
RA – rheumatoid arthritis
RBBB – right bundle branch block
R.D. – registered dietitian
Rehab – rehabilitation
reps. – repetitions
resp – respiratory, respiration
RN – registered nurse
R/O or r/o – rule out
ROM – range of motion
ROME – range of motion exercises
ROS – review of systems
rot. – rotation
RR – respiratory rate
RROM – resistive range of motion
R.T. – respiratory therapist/therapy
Rx – prescription; therapy; intervention plan; treatment
S
_
s – without
SACH – solid ankle cushion heel
SBA – standby assist
SCI – spinal cord injury
SC jt. – sternoclavicular joint
SED – suberythemal dose
sig – directions for use; use as follows; let it be labeled
SI jt. – sacroiliac joint
SLE – systemic lupus erythematosus
SLP – speech-language pathologist
SLR – straight leg raise
SNF – skilled nursing facility
SOAP – subjective, objective, assessment, plan
SOB – shortness of breath
S/P – status post
S/Sx – signs and symptoms
stat. – immediately or at once
STG – short term goal
sup. – superior
Sx – symptoms
T
tab – tablet
TB – tuberculosis
TBI – traumatic brain injury
TENS or TNS – transcutaneous electrical nerve stimulator/ stimulation
THA – total hip arthroplasty
THR – total hip replacement
TIA – transient ischemic attack
tid – three times daily
TIW – three times per week
TKA – total knee arthroplasty
TKR – total knee replacement
TMJ – temporomandibular joint
TNR – tonic neck reflex
t.o. – telephone order
TPR – temperature, pulse and respiration
TTWB – toe touch weight bearing
TV – tidal volume
Tx – treatment
tx – traction
U
UA – urine analysis
UE – upper extremity
UMN – upper motor neuron
UMNL – upper motor neuron lesion
URI – upper respiratory infection
US - ultrasound
UTI – urinary tract infection
UV ultraviolet
V
VC – vital capacity
VC – verbal cues
VD – venereal disease
VO or v.o. – verbal orders
Vol. – volume
v.s. – vital signs
W
w/c – wheel chair
W/cm2 – watts per centimeter square
WBC – white blood cell
WFL – within functional limits
wk. – week
WNL – within normal limits
wt. – weight
X
x – number of times performed (e.g. x3, x8, etc.)
Y
y/o or y.o. – years old
yr. – year
+1, +2 - assitance
♂ - male
♀ - female
↓ - down, downward, decrease, diminished
↑ - up, upward, increase
// - parallel, parallel bars (also // bars)
_
c - with
_
s - without
_
p - after
_
a - before
~ - approximately
@ - at
∆ - change
> - greater than
< - less than
= - equal
+ - positive
- - negative
# - number (e.g., #1) or pounds (e.g., 5# wt.)
/ - per
% - percent
↔ - to and from
→ - to, progressing toward, approaching
1° - primary
2° - secondary, secondary to
Muscles (Muscular System)
How many muscles are there in the human body?
Most sources state that there are more than 650 named skeletal muscles in the bo
dy. It might be difficult to count all of the muscles in the body if your going
to include the smooth and cardiac muscles.