Instructions in writing clinical reports SOAP method should be used in writing the clinical reports which include the

following: S: Subjective O: Objective A: assessment P: plan of treatment The following steps are to be used. Please note that you need to include all the relevant information whenever it is applicable and possible. Whenever it is not possible to obtain such information you just need to indicate this in the report by placing either A for non! applicable situations or O for information that you wish you have but you could not obtained. The following sub!headings are suggestions for what you could be loo"ing at on each section: 1) Subjective: What is it Subjective data involves information gathered by #uestioning$ correlates with the history! ta"ing component of the e%amination gathering of data from the patient and&or its family'. Where does it come from (' )istory *patient and& or its family' +' ,edical records. What type of information is itSubjective type of data may include the following: (. .eneral demographics a. Age b. .ender c. /ace d. 0ducation +. 1urrent condition& chief complaints a. Problem that led the patient to see" the service of physical therapy b. ,echanism of injury or disease including date of onset and course event c. Onset and pattern of symptoms d. 1urrent therapeutic interventions e. Patient&family e%pectations and goals f. Previous occurrence of the same symptoms 2. ,edical& surgical )% a. 1ardiovascular b. 0ndocrine&metabolic c. .astrointestinal d. .enitourinary e. .ynecological

3ntegumentary ,usculos"eletal euromuscular Obstetrical Psychological Pulmonary Prior hospitali4ion$ surgeries$ and pre!e%isting medical and other health issues *e.g. comorbidities such as diabetes and hypertension' 5. ,edications: a. 1urrent medications b. Previously ta"en for current condition c. 6or other conditions 7. Other clinical tests a. 8ab and diagnostic tests 9. 6unctional status and activity level a. 1urrent and prior functional status in self!care and home management *A:8' b. 1urrent and prior functional status in wor" *job&school&play'; community and leisure <. 8iving environment a. :evices and e#uipment b. 6amily and caregiver resources =. .eneral health status a. .eneral health perception b. Psychological function *memory$ depression$ an%iety' >. Social function a. Social activity b. Social interaction c. Social support (?. Social& health habits a. @ehavioural health ris"s such as smo"ing b. 8evel of physical fitness !) Objective This section is a component of the e%amination process. :ata gathered through direct observation. This can be performed through system review. Systems review may also point to the need of referral of other health care providers. The following are the main points to be considered on reviewing each system: (. 1ardiovascular& pulmonary system a. )ear rate *recorded as beats&minute' b. /espiratory rate *recorded as breaths&minute' c. @lood pressure d. Oedema in the e%tremities +. 3ntegumentary system

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a. S"in integrity *noting any area of loss of s"in integrity such as scraps$ cuts$ or open wounds' b. S"in colour *specifically noting colour abnormalities or changes such as redness around bony landmar" that might indicate the development of pressure sores' c. Presence of scar formation *this should include surgical scars and should indicate the location and appearance of each scar'

2. ,usculos"eletal system a. .ross symmetry *noting things such as leg length discrepancies and postural deficits such as a forward head or rounded shoulders' b. .ross /O, *noting patientAs ability to move e%tremities through available /O,' c. .ross strength *as noted through a gross strength screening loo"ing at overall muscle groups d. Are the colour and te%ture of s"in normale. 3s there any crepitus or abnormal sound in the joint when patient is movingf. 3s there any heat$ swelling$ redness in the area being observedg. 3s the patient willing to move5. euromuscular system a. .ross coordination of movements *can be noted primarily through observation of the patient during functional tas"s' b. @alance *noting general balance function during sitting and standing' c. 8ocomotion *ability to wal" or use a wheel!chair$ ta"ing note of assistive devices used$ distance$ surfaces$ and level of assist provided' d. Transfers *movement from one surface to another$ i.e.$ sit to stand; noting assistive or adaptive e#uipment and level of assist provided' e. Transitions *movement in bed from one position to another$ i.e.$ rolling over in bed; noting assistive o adaptive e#uipment and level of assist provided'

7. Other a. 1ommunication ability *noting any sign of aphasia or other communication deficits such as hearing or speech impairments' b. 1ognition *noting any cognitive problems such as loss of orientation to place$ time or self' c. 8earning style *noting the patient preference for receiving information$ ie$ demonstration$ verbal instructions$ written instructions' ") Assessment This section should include appropriate physiotherapy tests and assessment procedures you used to evaluate your patient (. Aerobic capacity& endurance

a. /esponse to activity: heart rate$ respiratory rate$ blood pressure b. Step tests c. 01. d. Auscultation e. Perceived e%cretion f. +. Anthropometric characteristics a. @ody composition *body mass inde%$ s"in ! fold thic"ness measurement' b. Weigh c. )eight *determine length discrepancies' d. .irth for oedema measurement or muscle atrophy 2. Arousal$ attention$ cognition a. Arousal and attention b. 1ommunication c. 1ognition *ability to process commands; e.g. mini!mental state e%amination' d. 1ommunication e. 1onsciousness *coma scales' 5. Assistive and adaptive devices a. Specify device being used during specific functional tas" b. :escribe patientAs ability to don&doff device as appropriate c. :escribe s"in condition related to use of the device d. :escribe safety ris"s associated with use of device 7. 1ranial and peripheral nerve integrity a. :ynamometry b. Tension tests c. Provocation tests d. Tactile tests including heat&cold$ pain and pressure. 9. .ait$ locomotion and balance a. :escribe activity b. 3ndicate any assistive$ adaptive$ orthotic$ prosthetic$ supportive devices used c. 3ndicate type of surface the patient is moving on d. 3ndicate distance travelled or amount of time activity is tolerated e. 8ist amount and type of physical assistance provided. 0%amples include: i. Supervision: no physical contact is needed ii. 1ontact guard assist: a hand on the patient but no physical assist provided iii. ,inimal assist: therapist provide minimal assistance iv. ,oderate assist v. ,a%imal assist f. umber of people needed to provide assistance g. 8ist amount and types of cues given h. :escribe gait pattern used if appropriate i. Step to

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ii. Step through or swing through :escribe gait deviations if appropriate *e.g. slap at initial contact$ toe drag during swing phase' When documenting gait$ include weight bearing status: i. 6ull weight bearing *6WP' ii. Partial weight bearing *PWP' iii. Toe touch weight bearing *TTW@' iv. Weight bearing as tolerated A:8 scales 6all scales

<. Boint integrity&mobility a. :escribe abnormal joint movements& end feels b. Apprehension tests c. Calgus&varus stress test d. Any other special tests =. ,uscle performance *including strength$ power and endurance' a. ,anual muscle test b. :ynamometry c. Timed activity tests d. A:8 scales >. /ange of motion a. Observation of functional /O, b. .oniometry c. ,uscle fle%ibility tests (?. /efle% integrity a. ,yotatic refle% scale b. Observation of postural refle%es c. Observation of primitive refle%es ((. Sensory integrity a. Stereognosis tests b. Cibration tests (+. Pain a. Pain #uestionnaires$ scales (2. Posture a. Observation of trun" alignment b. Observation of alignment of e%tremities c. 6orward bending test #) Plan of care (. Problem list: based on the above identify the problem list for your patient +. Asset list: what the patient can do which would help in implementing the plan of care. 2. $ong term goal: based on your problem list indicate the long term goal for the patient *the goal should be tas" specific and time specific'

5. Short term goals: based on the above indicate the short term goals that you will use to achieve the long term goal 7. %reatment plan: what you will do to achieve each short term goal