SOAP NOTES
Name: _____________________________________________________ Date: ____________________
Instructions: Write “S” for Subjective or “O” for Objective
_____1. Patient’s Range of Motion
_____11. “It is more of a dull aching pain.”
_____2. The mechanism of Injury (patient
explaining how injury occurred)
_____12. “2-inch laceration on right hand.”
_____3. Description of pain
_____4. Palpation of injury (feeling the injury
with your hands)
_____5. Patient gives medical history
_____6. Patient’s Blood Pressure and Pulse
_____7. “The pain started yesterday around
noon.”
_____13. “Lab results were negative.”
_____14. “If I take an Advil, the pain usually
goes away.”
_____15. “Age: 46 Height: 5’6” Weight:
164lbs”
_____16. “Patient appears pale and in
discomfort.”
_____17. “Abdomen soft and non-tender.”
_____8. “O2 sat recorded at 97%”
_____18. “I feel nauseated.”
_____9. “X-ray showed no fractures”
_____19. “Pulse irregular”
_____10. “My pain is about a 6 out of 10.”
_____20. “I am feeling dizzy.”
21. Place an “x” next to the statement that is more “OBJECTIVE”.
❑ “Patient was unable to complete a simple cooking task”
❑ “Patient is dependent in all cooking tasks”
22. Place an “x” next to the statement that is more “OBJECTIVE”.
❑ “Stomach pain at a level 8”
❑ “Abdominal tenderness when pressure applied”
23. Place an “x” next to the statement that is more “OBJECTIVE”.
❑ “Since taking new prescription, patient’s resting heart rate has increased by 20bpm”
❑ “Since taking new prescription, patient has been experiencing heart palpitations”
Instructions: Write “A” for Assessment or “P” for Plan
_____24. “Major Depressive Disorder, recurrent, without psychotic features.”
_____25. “The prognosis for the patient at this time is good because the patient is responding well to
treatment.”
_____26. “Will continue to monitor patient”
_____27. “Continue Fluoxitine at 10mg dose.”
_____28. “Transverse fracture of the distal tibia.”
_____29. “Referred patient to a dentist.”
_____30. “Provided low-sodium handout to patient.”
_____31. “Continue current Physical Therapy.”
_____32. “Patient desires to return to work but does not yet demonstrate the capacity for the required
sitting tolerance.”
_____33. “Recommended the use of lumbar support and regular performance of home program.”
_____34. “Asthmatic- exercise induced.”
_____35. “X-ray to rule out fracture.”
36. Place an “x” next to the statement that would be the most appropriate way to write an
ASSESSMENT.
❑ “Patient is improving”
❑ “Patient increased ROM 10 degrees.”
37. Place an “x” next to the statement that would be the most appropriate way to write an
ASSESSMENT.
❑ “Patient had difficulty with block stacking activity this session which was mastered
last session.”
❑ “Patient showed a decrease in accuracy over the last session.”
38. Place an “x” next to the statement that would be the most appropriate way to write a PLAN.
❑ “Increase physical therapy to more times per week.”
❑ “Have patient supplement PT with at-home exercises given by Physical Therapist.”
39. Place an “x” next to the statement that would be the most appropriate way to write a PLAN.
❑ “Continue taking medications as prescribed.”
❑ “Consider changing medication dosage.”
UNLUCKY LUKE
You are the Athletic Trainer on the sidelines for a game and
see the running back, 18-year-old Luke Adamgo, fall to the
ground after a play is over grasping his left ankle. You run over
to check on him and he said that he twisted his ankle when he
made a quick move and felt a “pop”. He tells you the pain is
intense, and it is starting to feel numb. When you asked how
bad the pain was on a scale of 10, he said a “9”. Upon
inspection, it is beginning to swell on the lateral side of his ankle.
You ask him to dorsiflex and plantar flex and he is unable to
move it without extreme pain.
You stand him up and he is also unable to put any weight
on it. You and one of the other Athletic Trainers carry him to the
sidelines. Upon palpation, he has tenderness and pain on the
lateral malleolus as well as the distal fibula. You run a heel tap
test to check for a possible fibula/tibia fracture. He did not feel
pain, which resulted in a negative result. Next, you run a Talar
Tilt Test and felt no major endpoint- leading to a positive result.
Even though you are not able to make an official diagnosis, you
know these results indicate a potential sprain of his CFL
(calcaneofibular ligament). You immediately place ice on the injury, lie him down and
elevate his ankle. You apply an ACE bandage snug, but not
tight, around his ankle.
One of the Athletic Training Assistants runs, and
grabs crutches and his parents are called down from the
stands. You tell them to take Luke to the Emergency Room
for further evaluation and to continue with Rice, Ice,
Compression and Elevation of his ankle.
Using the description from the scenario above, use the SOAP notes worksheet to
properly fill in the incident that took place.
SOAP NOTE
Patient Name:
Age:
Date:
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
Signature:
Date:
SOAP NOTES
ANSWER KEY
Name: _____________________________________________________ Date: ____________________
Instructions: Write “S” for Subjective or “O” for Objective
O Patient’s Range of Motion
_____1.
S
_____11.
“It is more of a dull aching pain.”
_____2.
S The mechanism of Injury (patient
explaining how injury occurred)
_____12.
“2-inch laceration on right hand.”
O
S Description of pain
_____3.
O Palpation of injury (feeling the injury
_____4.
with your hands)
S Patient gives medical history
_____5.
O Patient’s Blood Pressure and Pulse
_____6.
S “The pain started yesterday around
_____7.
noon.”
O
_____13.
“Lab results were negative.”
S
_____14.
“If I take an Advil, the pain usually
goes away.”
_____15.
“Age: 46 Height: 5’6” Weight:
O
164lbs”
O
_____16.
“Patient appears pale and in
discomfort.”
O
_____17.
“Abdomen soft and non-tender.”
_____8.
O “O2 sat recorded at 97%”
S
_____18.
“I feel nauseated.”
O “X-ray showed no fractures”
_____9.
O
_____19.
“Pulse irregular”
S
_____10.
“My pain is about a 6 out of 10.”
S
_____20.
“I am feeling dizzy.”
21. Place an “x” next to the statement that is more “OBJECTIVE”.
❑ “Patient was unable to complete a simple cooking task”
❑
X “Patient is dependent in all cooking tasks”
22. Place an “x” next to the statement that is more “OBJECTIVE”.
❑ “Stomach pain at a level 8”
❑
X “Abdominal tenderness when pressure applied”
23. Place an “x” next to the statement that is more “OBJECTIVE”.
❑
X “Since taking new prescription, patient’s resting heart rate has increased by 20bpm”
❑ “Since taking new prescription, patient has been experiencing heart palpitations”
Instructions: Write “A” for Assessment or “P” for Plan
A
_____24.
“Major Depressive Disorder, recurrent, without psychotic features.”
P
_____25.
“The prognosis for the patient at this time is good because the patient is responding well to
treatment. Continue current program.”
P
_____26.
“Will continue to monitor patient”
P
_____27.
“Increase Fluoxitine to 10mg twice per day.”
_____28.
“Transverse fracture of the distal tibia.”
A
_____29.
“Referred patient to a dentist.”
P
_____30.
P
“Provided low-sodium handout to patient.”
P
_____31.
“Begin Physical Therapy twice per week.”
_____32.
“Patient desires to return to work but does not yet demonstrate the capacity for the required
A
sitting tolerance.”
P
_____33.
“Recommended the use of lumbar support and regular performance of home program.”
A
_____34.
“Asthmatic- exercise induced.”
P
_____35.
“X-ray to rule out fracture.”
36. Place an “x” next to the statement that would be the most appropriate way to write an
ASSESSMENT.
❑ “Patient is improving”
❑
X
“Patient increased ROM 10 degrees.”
37. Place an “x” next to the statement that would be the most appropriate way to write an
ASSESSMENT.
❑
X
“Patient had difficulty with block stacking activity this session which was mastered
last session.”
❑ “Patient showed a decrease in accuracy over the last session.”
38. Place an “x” next to the statement that would be the most appropriate way to write a PLAN.
❑ “Increase physical therapy to more times per week.”
❑
X
“Have patient supplement PT with at-home exercises given by Physical Therapist.”
39. Place an “x” next to the statement that would be the most appropriate way to write a PLAN.
❑
X
“Continue taking medications as prescribed.”
❑ “Consider changing medication dosage.”
*Answers can vary or
be recorded slightly
different. This is just a
general idea.
SOAP NOTE
Patient Name:
Luke Adamgo
Age:
18 y.o.
Date:
7/16/18
SUBJECTIVE
Pt. states he twisted ankle during a play and felt a
pop. Pain 9/10. Experiencing numbness.
OBJECTIVE
Significant swelling over lateral malleolus. Cannot
actively dorsi or plantar flex. Cannot bare weight.
Tenderness and pain upon palpation. (-)Heel Tap
(+)Talar Tilt Test
ASSESSMENT
Possible Grade 3 sprain of CFL.
PLAN
Continue RICE treatment. Refer to ER for further
evaluation.
Signature: FirstName LastName,
ATP
Date:
7/16/2019