MAT111 - SOAP Notes

Hey guys!

This morning Berly reviewed how to be a proficient SOAP note writer. You all have access to the lecture notes she had displayed on the board in your MAT111 class.

Here are some highlights from the lecture/tips on writing your notes:

~ Be specific, clear, and concise.

~Too little information will be detrimental to your notes, esp. if they're requested for legal or medical use. Ex. "FBM [full body massage]. Cl feels great."

~Too much information takes too long to write and doesn't look professional. Sorting through excess info takes time and you may miss the important pieces. Ex. "Massage began at the head. Circular friction was applied from the base of the skull to forehead. Cross fiber friction applied to the forehead with the thumbs..."

~ "S" stands for "Subjective," or what the client SAYS. Ex, "Cl. stated 'I worked out yesterday. My hamstrings are sore."

~ "O" stands for "Objective," or things you OBSERVE. Ex, "Multiple adhesions found in R rhomboid major and minor along the scapula." Or, "Cl's feet laterally rotated."

~ "A" stands for "Assessment," where you DESCRIBE your treatment and RECORD any changes in your client. Ex, "Full body, 60 min Sw. tx. [treatment] including back, legs, feet, arms, hands, and chest. Adhesions in rhomboids reduced. Cl. claims to feel "very relaxed."

~ "P" stands for "Plan." What is your PLAN. What do you suggest your client does? For example, "SMT advised cl. to hydrate, esp. day of tx. Rebook appt. in 3 wks for 60 min. Sw. tx."

~ Abbreviate. There are a list of medical abbreviations somewhere (I will find them eventually). Abbreviations like "cl." for client, "tx." for treatment, "R & L" for right and left, etc. Be careful not to over abbreviate or other therapists may not be able to read your notes. If you have a doubt, spell it out.

~ You can write things you want to remember for the next time your client comes in. "Cl. is sensitive to candle smells," or, "Cl. requested no bolster," or, "Cl. preferred lotion, claimed sensitivity to oil." It isn't all medical-specific information.

~ Write your notes as soon as you can after you perform the treatment. The information will be fresh so you'll remember more important details and it will be accurate.

~ Listen to Berly's feedback!

I hope these tips help! Use them as a reference when writing your notes.

And have a good week :-)

~Jess