Sports Medicine II—SOAP Note Practice
S=
A=
O=
P=
Name ______________________
Page |1
For each of the following statements that could be entered into a patient’s file, write S, O, A, or P to the left of the statement
corresponding to which section of the SOAP note it belongs in.
_____1.
Patient rates his headache pain as 4/10.
_____2.
Patient states “she thinks she has frozen shoulder.”
_____3.
Patient should ice left shoulder after pitching.
_____4.
Patient prescribed Naprosyn for pain and inflammation.
_____5.
Patient to wear walking boot on right foot for 2 weeks.
_____6.
Patient referred to neurologist for migraines.
_____7.
Patient rates low back pain 6/10 upon arrival to clinic.
_____8.
Point tenderness over left tibial tuberosity.
_____9.
Crepitus felt over distal radial head.
_____10.
Subacromial bursitis
_____11.
Fracture of C 5 spinous process.
_____12.
Edema present over right lateral malleolus.
_____13.
Positive Thompson test right gastrocnemius.
_____14.
Negative bump test left lower extremity.
_____15.
Left medial epicondylitis
_____16.
HR 82 bpm
_____17.
Patient reports numbness and tingling in left arm.
_____18.
Patient to report to physical therapy 3 times a week for 4 weeks.
_____19.
Deformity observed over right 1st MCP joint.
_____20.
Patient may gradually return to sports.
Sports Medicine II—SOAP Note Practice
Translate each phrase below into a full English phrase or sentence.
_____21.
to PT per w/c turn Pt. qh
_____22.
Dx: RA: R/O SLE
_____23.
c/o SOB p bilat. UE PNF
exercises
_____24.
Pt. c/o R hip pain p amb ≈
300 ft. x 1 c a walker FWB R
LE
_____25.
D/C US in area of R SI joint
_____26.
Fx L clavicle & subluxation R
SC joint
Name ______________________
Page |2
Sports Medicine II—SOAP Note Practice
Name ______________________
Page |3
Translate each sentence or phrase written in English into a sentence or phrase written with abbreviations.
_____27. Intervention plan: once per
day, activities of daily living training,
ultrasound to 1.0 to 1.5 watts per
centimeter squared to anterior
superior aspect of right knee for 5
minutes
_____28. The patient has a below-theknee amputation. Has used a patellar
tendon bearing prosthesis with a solid
ankle cushion heel foot for the past 20
years.
_____29. The patient’s heart rate
increased 20 beats per minute after
only 2 minutes of self-care activities of
daily living
_____30. The medical diagnosis is left
chronic renal failure
_____31. The muscle function test
reveals strength 4/5 throughout the
upper extremities bilaterally.
_____32. The patient may be 50
percent partial weight-bearing left
lower extremity per verbal order of
Dr. Smith.
Sports Medicine II—SOAP Note Practice
Name ______________________
Page |4
Write a SOAP note given the following scenario.
A 14 year old male basketball player falls to the floor after going up for a layup. When you get out to the court, you notice he
is holding his right ankle. He complains of pain on the lateral aspect of his ankle. He states that his ankle rolled under him
when he came down from the layup. You perform bump and squeeze tests to rule out a fracture and both are negative. You
get him up to take him to the sideline for further evaluation. He is unable to put any weight on his foot and is carried off by
two teammates. Once removing his shoe and sock, you see edema over his lateral malleolus, no deformity, and minor
ecchymosis. Point tenderness over lateral malleolus and talofibular and calcaneofibular ligaments. Talar tilt test positive for
gross laxity and pain. Negative Kleiger’s test. You suspect a grade 3 lateral ankle sprain. Athlete to rest, ice, wear a
compression bandage, and elevate tonight. Athlete given crutches and crutch walking instructions. Athlete to follow up with
orthopedic physician for imaging.
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Sports Medicine II—SOAP Note Practice
Name ______________________
Page |5
Write a SOAP note given the following scenario.
An 18 year old female soccer player reports to the athletic training room holding the left side of her head and complaining of a
headache. She states she was struck in the head by another player’s head when they both went up to head the ball at practice.
She sates that she did not lose consciousness, but fell to the ground due to dizziness. She says that the dizziness has subsided
now and she has a headache with pain rated 6/10 with 10 being the worst. Athlete reports current symptoms of headache,
pressure in head, a “feeling of things being wrong”, and sensitivity to light. Edema is present over left parietal bone. Athlete
is unable to stand on one foot for more than 5 seconds. Results of SCAT-3 are consistent with a concussion. Athlete is to
refrain from all physical and mental activity until symptoms subside. Ice given for edema. Parent contacted and made aware
injury as well as symptoms of traumatic brain injury. Both parent and athlete told to seek medical attention if symptoms get
worse. Athlete to return to athletic training room tomorrow for re-evaluation.
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P: