Business of OMT: The Osteopathic SOAP note PdTF III Curriculum Katie Dickey OMS III PdTF IV Principles of Instructional Design kdickey@westernu.edu 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?