Record Keeping in Sports Medicine

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Record Keeping in Sports Medicine

• Why is it so important?

2
Patients Record

• Sent to therapist from doctor that performed
  initial evaluation
• Read by clinician(s) responsible for therapy
• Includes
• Physicians diagnosis (Dx)
• Doctors name
• Patient contact information
• Patients History

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First things First

• Patients History (Hx)
• A form that describes the patients medical
  history and chief medical complaint.
• Includes
• Age
• Past illnesses
• Inherited conditions
• Previous therapies
• Prescribed medications
• Precautions associated with patients condition
• Facts that are important considerations in the
  rehab process.

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SOAP Notes

• An organized method of documenting a patients
  status on his or her chart that includes
  subjective findings, objective findings,
  assessments, and plans for each problem
  experienced by the patient.

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What is a SOAP note?

• Concise, easy-to-read method of documenting the
  patients health status.
• Effective in recording progress as well as
  difficulties encountered as well.
• Ensures consistent patient care by the various
  members of the rehabilitation team.

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What does SOAP stand for?

• S Subjective findings
• O Objective findings
• A Assessment
• P Plan

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SUBJECTIVE - HISTORY

• Items they tell you about the injury or illness
• What happened
• How it happened
• Where it happened (e.g. surface, weather
  conditions, etc.)
• When it happened
• Previous history
• Any unusual noises/sensations heard/felt
• What treatment has been done for it
• Etc.

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SUBJECTIVE

• To make this clearer, the subjective statements
  should be prefaced with words such as, Patient
  states. or Patients family thinks.
• Use the patients own words set off with
  quotation marks whenever possible.
• Examples
• Patient states that his right leg hurts while
  walking.
• Family states that patient was unmotivated at
  home.
• Patient complains of feeling sick to her
  stomach.
• Patient feels coach is pushing him too hard to
  return to play.

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OBJECTIVE - Physical Findings

• Everything you SEE and/or can measure during
  treatment
• Results of limitations, instability, apprehension
• General appearance (discoloration, deformity,
  rigidity)
• Edema (swelling)
• Temperature
• ROM
• Gait analysis
• Method of transport to you

• Muscle strength
• Muscle tone
• Endurance
• Posture
• Sensation
• Mental alertness
• Respiration
• Pulse
• Skin/wounds
• Stress tests (reflexes, specific tests for body
  parts)
• Functional tests

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OBJECTIVE

• Another person can be used to verify this
  information.
• Examples
• Patient refused treatment the past three days.
• Patient keeps knees bent during ambulation.
• Patient keeps head and trunk forward during
  ambulation, but will correct it with cueing.
• Patient is capable of 30 degrees of shoulder
  flexion.

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ASSESSMENT

• A licensed professionals opinion/educated guess
  of the patients condition, progress, or
  potential obstacles to rehabilitation.
• The exact injury/illness may not be known
• Possible 2 L anterior talofibular ligament
  sprain
• Suspected site and anatomical structures
• 1, 2, 3
• Strain, sprain, fracture, etc.

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ASSESSMENT

• Examples
• Patients balance has improved and is now fair.
• Patient seems depressed.
• Patient has developed soreness from the custom
  brace.
• Patient seems anxious about going home.
• Range of motion has increased in patients right
  shoulder this week.

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PLAN - What to do next

• Treatment the patient will receive
• First aid treatment, splint, wrap, crutches,
  re-evaluate tomorrow a.m.
• Short Long term goals
• Expected functional outcomes
• Frequency per day/week
• Treatment progression
• Patient education home instructions
• Referral
• Discharge notes

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PLAN

• Examples
• Advance the patient to the use of a cane this
  week (as able).
• Continue to encourage patients participation in
  exercises.
• Make arrangements to go to the local gym.
• Talk to the coach to discuss potential flaws in
  athletic skill technique.
• Schedule re-evaluation.

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How do you write SOAP notes?

• The written record organizes the info from the
  history physical exam.
• It must clearly communicate the patients
  clinical issues to all members of the health care
  team.
• It should facilitate clinical reasoning
  communicate the patients clinical issues to all
  members of the health care team.

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SOAP Notes

• Write it utilizing the 7 key attributes of a
  symptom
• Write it as soon as possible before it fades from
  your memory
• May have to take notes at first until you gain
  experience
• Date, Chief Complaint, Present Illness, etc.

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Sample SOAP Note
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Is that it for note taking?

• No!!! Progress notes should be written after
  each session, and at times, may follow the SOAP
  note format.
• Should track the changes, both good and bad, in
  the patients progress.
• Important in protecting rehabilitation team from
  potential litigation.
• The more detailed the better.
• Progress notes should be concise, but should
  provide enough detail to allow a staffperson who
  has never worked with the patient to understand
  the treatment and progress up to that point and
  continue with the treatment.