MODULE 1. INTRODUCTION TO CLINICAL EXERCISE ASSESSMENT AND PRESCRIPTION
Unit 1 Concepts in clinical exercise assessment
Learning Activity 1.2. Preparing SOAP notes
The first step in the rehabilitation process is performing a thorough clinical assessment in order to define
patient limitations and develop goals. You should develop a strategy for summarising the important
points of each case. The SOAP note is one approach. SOAP is an acronym for Subjective data, Objective
data, Assessment and Plan for treatment.
SOAP notes are one type of note documenting clinical care used in health clinical settings. The major
goal of this type of note is to outline clinical care in an analytical way (A) that is based on empirical data
(S and O) leading to specific outcomes (P) (Cameron & Turtle-Song 2002).
Ball, D., & Murphy, B. (2008). Taking SOAP notes. IDEA Fitness Journal, 5(4), 32-35. [EBSCO]
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of
Counseling and Development, 80(3), 286-292. [EBSCO]
Briefly describe the four components when using the SOAP not format
S
Subjective
O
Objective
A
Assessment
P
Plan
Implement the SOAP note format to summarise your findings from the following two injury scenarios in a
concise and effective manner so that a potential rehabilitation plan can be initiated. For each of the steps
involved use your imagination and previous experiences to consider the following.







Complaints and rating of pain
Location of injury
Previous history
What is their ultimate goal of rehab?
Is any swelling, discoloration, deformity present?
Assess AROM, PROM and RROM
Perform any special tests associated with the injury situation
EHR503 Clinical Assessment and Exercise Prescription in Rehabilitation | Charles Sturt University
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MODULE 1. INTRODUCTION TO CLINICAL EXERCISE ASSESSMENT AND PRESCRIPTION
Unit 1 Concepts in clinical exercise assessment
Scenario A
A netball player complains of acute achilles tendonitis two days after practice begins.
Maffulli, N., Sharma, P., & Luscombe, K.L. (2004). Achilles tendinopathy: aetiology and management.
Journal of the Royal Society of Medicine, 97(10), 472-476.
S
O
A
P
Scenario B
A diver on your swim team has a well documented case of glenohumeral joint instability which she has
not had surgically repaired and needs treatment advice for a recent sublaxation.
Cordasco, F.A. (2000). Understanding multidirectional instability of the shoulder. Journal of Athletic
Training, 35(3), 278-285.
S
O
A
P
EHR503 Clinical Assessment and Exercise Prescription in Rehabilitation | Charles Sturt University
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MODULE 1. INTRODUCTION TO CLINICAL EXERCISE ASSESSMENT AND PRESCRIPTION
Unit 1 Concepts in clinical exercise assessment
Jigsaw: The following statement is from Cameron and Turtle-Song (2002). Type the words in the correct
places to complete the statement.





framework
SOAP notes
understand
patient
SOAP notes
Not only does the
format allow for thorough documentation, but it
also assists nutrition in representing clients concerns in a holistic
, thus permitting practitioners to better
the concerns and needs of the
patient. Cameron and Turtle-Song (2002) suggest that the recommendations and use of
are relevant to a wide array of
setting.
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal
of Counseling and Development, 80(3), 286-292
Key Points: Outline three (3) key learning points from this topic.
1.
2.
3.
Professional Vocabulary: Define the following acronyms as part of your professional vocabulary.
AROM
PROM
RROM
SAID
GAS
PRE
EHR503 Clinical Assessment and Exercise Prescription in Rehabilitation | Charles Sturt University
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