SOAP Notes: SUBJECTIVE

Question 1

What is the “S” in “SOAP”?

Answer 1

S = SUBJECTIVE
• Info obtained from the patient, giving his perspective on his condition or treatment. Keep it from the client’s perspective (or caregiver’s if needed)
• Cannot be verified or measured during treatment session (Even pain is subjective)
• Patient reports limitations, concerns, problems
• Statements only relative to treatment- pain, fatigue, expressions of feelings, attitudes, concerns, goals and plans
• Subjective note may be facility-specific.
• Can QUOTE, PARAPHRASE or SUMMARIZE

Question 2

How to be specific in a Subjective note:

Answer 2

Instead of quoting “My shoulder hurts,”
DIG DEEPER. Ask questions. Better:
“Client states his R shoulder “throbs” when he tries to put his shirt on.”
(Specific, and even gives occupation affected)
• Always ask about PAIN, and try to get specific level. Use number scale (1-10), verbal (severe/mild), or visual analogue (faces). May also talk to nurse about this.

Question 3

Examples of Subjective notes:

Answer 3

• “I don’t need therapy.”
• Pt reports being fearful of leaving her home.
• Client reports his MD ordered “some home care for a few days to work on transfers.”
• Client reports, “I will not wear my face mask, it is my face and I do not care about scarring.”
• Client expressed doubts about returning to work.

Question 4

How to record “S” note if patient cannot speak?

Answer 4

• Client unable to communicate due to aphasia.
• Pt able to follow 50% of commands, however, continues to be unable to verbally communicate due to trach.
• Pt used message board to say he wants to be able to complete self care with I.
• Client nods appropriately when asked questions during therapy.
• Can note baby reactions, or use descriptives like “grimaces” or “nods” or “grunts.”
• Can note BP, temp., etc. to show stability.

Question 5

“S” Notes in Pediatric Population

Answer 5

• Report what the PARENT/CAREGIVER says.
• Mother reports that child was able to complete self feeding with use of the R hand yesterday.
• Father reports that child refuses to wear his splint at night.

Question 6

“Skilled Conversation”

Answer 6

• OTP must direct conversation to get SOAP note (avoid idle chit-chat, but still build a friendly relationship)
• Direct conversation to topics meaningful to client care.
• Guide toward history, problems, needs, support systems, strengths, living situation, goals, etc.
• Ask: How do you feel you’re doing in therapy? How are you feeling about your upcoming discharge? How is your child’s home exercise program going?

Question 7

How to address PAIN in Subjective

Answer 7

If pain is relevant, ask about it and report Pt.’s level/info. (ie: Pt. reports 5/10 pain in L shoulder); Also, carry addressing this pain through OAP!