Writing with Clarity
Jargon
Avoid the use of jargon (slang terms, abbreviations, etc.) when writing. The use of slang terms can be
considered inappropriate and possibly confuse your reader. If the document is unclear and difficult to
comprehend, your credibility as a writer may be compromised.
Abbreviations & Acronyms
Abbreviations and acronyms can be used to save space in documents where lengthy terms are being
repeated. When you feel it is necessary to use abbreviations, write out the term when you first
reference it, placing the abbreviation for it within parenthesis. When you utilize the word later, your
reader will be aware of its meaning. Avoid overuse of abbreviations and acronyms. If you utilize too
many within one document, your reader may become confused.
Be Concise
Being concise in your writing does not mean being short. Using concise language means choosing strong
words to eliminate unnecessary and repeated phrases. Avoid being vague; by being more direct in your
statements, you will have more powerful sentences. Pare down your sentences to the essential
message.
S.O.A.P. NOTES
Written for every patient visit, SOAP notes are the standard method of documenting treatment sessions.
They are found in every patient chart and may be handwritten or electronic. Most importantly, SOAP
notes are instrumental to determining the best possible treatment plan for your patient.
Subjective
In the beginning section, the PT should record information of clinical significance that is furnished by the
patient, the patient’s family or another caregiver. Below are some common elements:
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Age and gender
Functional activity level
Living environment
Health status and history
Employment status/information
Allergies
Date of injury
Chief complaints
Location, type and intensity of pain
Patient goals
Objective
Here the PT will document the specific, measurable and repeatable data concluded from the session.
Objective information can include:
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Visual inspection
Palpitation
Joint range of motion
Gross muscle strength
Neurological examination
Special tests
Assessment
The assessment should interpret the collected information, consider the patient’s impairments and
place them in a diagnostic category. Essentially, the assessment is the “why” portion of the SOAP note,
which seeks to justify the chosen plan of care.
The assessment can include a problem list, short term goals, long term goals, and discharge goals.
Plan
The final section should detail the treatment frequency, duration and type. The plan should also include
planned interventions such as specific modalities, manual therapy or therapeutic exercises.
Resources
McComas K. Daily progress notes: SOAP note format. Ohio State University Web site.
people.ehe.osu.edu/dgranello/files/2009/04/soap-notes.pdf. Accessed November 5, 2014.
Ball D, Murphy B. Taking soap notes. IDEA Health and Fitness Association Web site.
http://www.ideafit.com/fitness-library/taking-soap-notes. Accessed November 5, 2014.
Soap notes. Thomas Jefferson University Web site. http://www.jefferson.edu/university/jmc/students/
alpha-omega-alpha/guides/clinical-years-guide/soap-notes.html. Accessed November 5, 2014.