PTA 211 Assessing a SOAP note: (indicate the content)

HP & Paraffin             Ultrasound                 NMES              ES to reduce pain

 This semester, both the SOAP note and the assessment will be submitted electronically so that you have the opportunity to become more familiar with keyboarding and timely submission of your documentation. All SOAP notes and assessments for them for PTA 211 Physical Agents must be submitted electronically to behrensb@mccc.edu using this form. This will require collaboration and communication among you and your classmates.

 

Clinician:_________________________/30    Reviewer's Name:_____________________/30

 

*any additional space may be used to  include content  missing from the SOAP note

Points

YES

NO*

1

Was black ink used by the clinician and did he or she cross out blank lines or spaces?

2

 

 

2

Was the patient's full and real name used and did it include the date?

2

 

 

3

Was everything that happened in the treatment session in the SOAP note?

 

 

3

 

 

4

Was only relevant patient information included in the subjective portion?

 

2

 

 

5

Is the information in the objective section detailed enough that it could be easily reproduced by another clinician? 

 

Were all parameters present that are necessary to know what was done and where?

 

4

 

 

6

Is the assessment section valuable and meaningful? 

 

 

3

 

 

7

Is everything that is contained in the assessment section first documented either in the subjective or objective sections?

 

 

3

 

 

8

Is the plan section meaningful (e.g. not just “cont. with  POC”)

3

 

 

9

Were abbreviations used appropriately?  Were only PTA Program Approved abbreviations used?

2

 

 

10

Were any errors in the documentation indicated correctly?

1

 

 

11

Was white out utilized or was anything obliterated?

1

 

 

12

Was an addendum added and if so was it documented correctly?

1

 

 

13

Was the documentation legible and signed using a professional designation?

1

 

 

14

Is the clinician’s signature readable, and if not, was the name also printed?

1

 

 

15

Is the SOAP note easy to read and follow?

1

 

 

If you were to read this note and then treat this patient on your first day of a new job, would you feel comfortable going in to treat the patient?  Did it provide a clear and well- rounded understanding of what the patient had received from the previous clinician and you would then be doing during this treatment session and why?

 

 

Submission of this form with evidence of contributions from both the clinician and reviewer indicates that both individuals understand and accept responsibility for the documentation and its quality. Both individuals will receive a grade for each submission that reflects their portion of the work. Failure to review submissions by classmates will have a negative impact on one's ability to appropriately document in SOAP note formats as it is viewed as an activity that requires review and practice to become proficient.  Each learner is required to submit his/her portion of the work electronically to behrensb@mccc.edu indicating his/her role.

 

Document all aspects of the SOAP note as appropriate.

The S refers to the information reported subjectively by the patient.

The O pertains to any objective measurements or treatment interventions that were administered to address the patient's complaints from the S.

The A refers to after treatment and your assessment utilizing your professional judgement regarding the impact of what was done during this session and the patient's response to the interventions that were employed. In other words, did what you used in the O have any impact on the S that your patient reported?

The P sums things up and it refers to your plan for the future based upon your assessment of what happened after you utilized the O to address the S that your patient had initially reported to you.

S---O---A---P

                                                                                                                           

 

Progress Note Date:                            Patient Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PTA 211 SOAP note 7/15 bjb