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Intro. to clinic > SOAP notes > Flashcards

Flashcards in SOAP notes Deck (12):
1

S

subjective
update the complaint
How are they today?
How have they been since the last adjustment?

2

accurate description of the patient's complaint

onset
provoking/palliative
quality
radiation
severity
time/frequency

3

O

objective
what you observe
reports form other doctors
dingins from your exam
radiology reports
inficators of subluxation

4

PART is part of..

Objective findings

5

PART

pain/tenderness
asymmetry/alighment
ROM abnrmality
tissue, tone, texture, temperature abnormality

6

pain/tenderness is identified by

observation
percussion
palapation
provocation

7

pain/tenderness is evaluated by

location
quality
intensity

8

assymetry/alighment

identified on a sectional or segemntal level
observation, static palpation, diagnostic imaging

9

ROM abnormality

changes in active, passive and accessory joint movment can result in increase or decrease of sectional or segmental mobility
identified by: observation, motion palpation, ROM testing

10

tissue, tone, texture, temperature abnormality

chagnes in characteristics of contiguous and associated soft tissues
(skin, fasica, muscle, ligament)
identified through observation, palaption, instrumentation, tests for strength

11

Assessment

impression of current condition
includes diagnosis
no change, improved, worse
what you think
assessment reflects doctor's judgement

12

Plan

care rendered
short term goals
long term goals
discussions with patient
scheduled follow up