Business of OMT: The Osteopathic SOAP note

advertisement
Business of OMT:
The Osteopathic SOAP note
PdTF III Curriculum
Katie Dickey OMS III PdTF IV
Principles of Instructional Design
[email protected]
Objectives
• PdTF III will be able to accurately describe the
four sections of a SOAP note by the end of the
lecture.
• PdTF III will be able to accurately document
structural exam findings on an osteopathic
SOAP note
• PdTF III will be able to correctly document an
assessment and plan for an osteopathic SOAP
note by the end of the lecture.
SOAP
• Subjective
• Objective
• Assessment
• Plan
SOAP
• Subjective
–
–
–
–
–
–
–
Patient history: OPQRST
Medications/Allergies
Past Medical History
Past Surgical History
Family History
Social History
Review of Systems
• Objective
• Assessment
• Plan
SOAP
• Subjective
• Objective
– Vital Signs
– Physical Exam
– Osteopathic Structural Exam
• Specific exam findings.
• Assessment
• Plan
SOAP
• Subjective
• Objective
• Assessment
– Diagnosis
– Ie. Somatic Dysfunction & what regions
• Plan
SOAP
•
•
•
•
Subjective
Objective
Assessment
Plan
– Treatment
– Ie. What OMT techniques you used, follow-up,
lifestyle changes recommended
• Insert image of soap note.
Any questions?
Download