In the following scenario, which part of the SOAP notes is the therapist filling out?

The therapist takes a moment to think about the results of the massage session she just had with John. His condition, shoulder pain, seems to have improved. Last week, he could barely move it and today he had almost full range of motion.

object observations
subjective observations
assessment
plan

Answers

Answer 1

The part of the SOAP notes that the therapist is filling out is the object observations.

The acronym SOAP is a used for methods of documentation by healthcare provider which stands for:

Subjective observations: In this section, the personal complaints of the patients is observed and documented.

Object observations: In this section, the patients encounters or findings based on the information given by the patient is documented. For example: physical examination findings, laboratory findings, and imaging results.

Assessment: Decisions of the proper diagnosis is made based of the findings and is documented.

Plan: The needs for further steps to treat a patient is documented in this section.

Therefore, the part of the SOAP notes that the therapist is filling out is the object observations. This is because it involves the physical examination findings of John who has improved from shoulder pain.

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