Lecture 1

Question 1

Purpose of Documentation?

Answer 1

• Protects rights of patients and providers
• Methods of communication b/w health professionals
• Insurance coverage/reimbursement decisions may be based on notes
• Helps achieve consistent care

Question 2

SOAP?

Answer 2

Subjective
Objective
Assessments
Plan

Question 3

S of SOAP

Answer 3

• Their history/lifestyle
• Emotions/attitudes
• Their pain/ how it affects them
• Response to treatment
• Anything that comes out of their mouth

Question 4

O of SOAP

Answer 4

What health care professionals measure/observe
- Was part of existing medical file
- Result of an objective measure
- Part of treatment given/ability to perform treatment

Question 5

A of SOAP

Answer 5

Contains 4 categories:
- Problem list [summarizes the problems as written in both S and O, provides index of suspicion]
- Long-term goals
- Short-term goals
- Summary [opportunity to draw correlations between SOA, any inconsistencies]

Question 6

P of SOAP

Answer 6

Plan details the treatment
- Includes treatment regime, including: Frequency, clinical treatments, exercises, how many times they were seen, and where rehab taking place
- Equipment needed
- Referrals to other services

Question 7

When do we need to chart?

Answer 7

• If assessing or providing treatment to patient or athlete
• If communicating with patient/athlete regarding injury
• If communicating with other health care pros
• Any additional info received

Question 8

What other things go into the SOAP notes?

Answer 8

• Health history form
• Consent to treatment
• Permission to release medical info
• Copy of referrals
• Copies of anything given to patient/athlete

Question 9

3 Primary reasons for consent

Answer 9

1. Protects individuals right to ‘security of person’
2. Enhances communicationa nd trust b/w caregiver and care receiver
3. Risk management measure to avoid litigation

Question 10

7 Criteria for valid informed consent

Answer 10

• Informed
• Competence
• Mental capacity
• Voluntary
• In best interest of patients
• Specific and not misrepresented
• Opportunity to ask questions