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A format/style of documentation in healthcare
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Any document can be written in this style
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Originally designed for Osteopathic medicine
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Designed to achieve a more structured evaluation
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Includes a thorough hx & physical exam
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Allowed for more accurate Dx
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Organized, concise document
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Utilizes medical abbreviations

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Liability: legal document
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Communication: method to communicate w/ other healthcare professionals and/or your staff
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Insurance: third party reimbursement
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Progress Report: review report to decide if Tx is effective
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Research: to collect injury data statistics
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Education: to improve quality of care

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Oregon:
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“Athletic trainers are required to accept responsibility for recording details of the athlete's health status and include details of the injured athlete's medical history, including: name; address; legal guardian if a minor; referral source; all assessments & test results, by date of service provided; treatment plan and estimated length for recovery; record of all methods used; results achieved; any changes in the treatment plan; record of the date the treatment plan is concluded and provide a summary; sign and date each entry.”

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Write it as soon as possible before it fades from your memory
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May have to take notes during the evaluation initially
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Notes should organized & chronological
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Use subheadings
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Underline headings
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Notes should include past & present examinations, tests, Tx, & outcomes

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Notes must be legible!
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Never use “I” refer to your professional title
 i.e. ATC, PT
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Use quotes whenever possible
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Do not use hyphens
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Confused w/ minus signs
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Use black or blue ink only
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Sign all evals and progress notes

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Information obtained from Pt
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Very important to get a good Hx
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The background of the injury will often give you the answer
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Includes:
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Hx: pertinent background information
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MOI or HPI: how, what, when, where of the injury
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C/O: Pt’s sx including description of pain
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Meds: current medications being taken (Rx, OTC, sup)
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All: any allergies

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Hx:
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PSHx, PFHx, Past Tx, social hx, prev injuries, change in activity,
MOI:
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Any unusual noises/sensations heard/felt
Onset of injury: acute or gradual (chronic)
C/O: complains of (or chief complaints - CC)
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Pain scale (1-10)
Location, severity, & type of pain
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Burning, stinging, sharp, dull, deep, nagging, radiating, constant, @ night, in a.m.
Pain worse during or after activity
Limitations from pain
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What aggravates & alleviates pain
Meds:
All:

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Clicking/Locking:
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Meniscus/labral injury
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Pop:
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Ligament injury
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Patellar/GH dislocation
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Muscle tear
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Snapping/Popping:
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Tendonitis
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Bursitis
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Pulling:
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Muscle strain

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Physical findings:
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Everything you observe, palpate, or test
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Typically measurable/repeatable
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Includes:
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Observation
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Inspection
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Special Tests
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Neurovascular
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ROM
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MMT

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Begins the moment you first see them
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Assess the individual’s state of consciousness & body language
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May indicate pain, disability, fracture, dislocation, or other conditions
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Note their general posture, willingness & ability to move
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When you start your exam:
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Check bilaterally & think outside the box!
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Don’t get caught up in the specific area

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ALWAYS compare bilaterally
Gait & posture
Obvious deformity
Bleeding
Mental alertness – state of consciousness
Discoloration/Ecchymosis
Swelling
Atrophy/Hypertrophy
Scars
Skin

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Palpation:
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Deformity
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Point tenderness
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Temperature
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Crepitus
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Special Tests: (+/-)
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Fx tests
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Specific tests for body part
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Functional tests

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(NV) Neurovascular: (G or P, +/-, WNL/N)
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Myotomes - Strength
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Dermatomes - Sensory
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Skin Temp/Color
Cap refill
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Pulse/BP
Reflexes (superficial & deep tendon)
ROM: (in degrees)
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AROM/PROM
End feel
MMT/RROM: (out of 5)
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Strength tests
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Break tests

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0/5: no contraction
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1/5: muscle flicker, but no movement
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2/5: movement possible, but not against gravity
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3/5: movement possible against gravity, but not against resistance by the examiner
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4/5: movement possible against some resistance by the examiner
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Can be subdivided further into 4 – /5, 4/5, and 4 + /5
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5/5: normal strength

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Your professional opinion of the type of injury/illness
Based off the subjective & objective portions of the exam
Include:
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Anatomical location
Severity
Description
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The exact injury/illness may not be known
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Exp: Possible 2 ° L ATFL sprain

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Tx the patient will receive that day
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Ice, splint, crutches
Plan for further assessment or reassessment
Patient/Family education: Home instructions
 i.e.: Concussion Take Home Instructions
Referral
Short & Long term goals: need to be measurable
Expected functional outcomes
Equipment needs
Plans for discharge/RTP

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Frequency
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Location
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Duration
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Type
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Progression
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Example of generic plan:
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Pt will be seen TIW x 6 weeks to include TE & modalities as needed

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Goals that will allow Pt to achieve long-term goals
Record specific rehab ex’s
Record any modalities used & exact parameters used
Day to day or weeks
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Example:
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Increase R shoulder flexion to 145 o (from 125 o ), increase function so Pt can comb their hair c R hand in 7 days.
List specific stretching & functional exercises

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Expected outcomes
Includes:
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What is the outcome
What will it take to achieve that outcome
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Include measurements and specific interventions for each goal
What conditions must exist for a good outcome
Example:
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Return to full strength (5/5 from 4/5), full ROM
(170 o from 145 o ), return to volleyball
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List specific strength ex’s, stretches, & sport specific activities

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Written after each eval/rehab session
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Can be performed as SOAP note or as a summary
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Include response to Tx & type of Tx
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Progress made towards short-term goals
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Changes in Tx or goals
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Important notes:
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Seen by physician
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Results of diagnostic tests
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RTP status

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Response to treatment & rehab
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Decreased/increased pain
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Include why: from rehab, standing all day, etc
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Overall psychological profile (i.e. bored)
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Reassessing subjective information from previous notes
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Change in function
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Change in pain (location, type)
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Patient compliance issues c ex’s

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Tx provided
Reassess & compare measures that may have changed
Note changes in ROM, strength, functional ability
Indicate any changes or special notes for rehab
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Change in modality parameters
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Assistance needed/not needed during exercises
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Added/decreased weight/reps/sets/frequency
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Added or changed exercises

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History
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Observation/Inspection
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Palpation
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Special Tests