Patient/SOAP questions

Patient Questions

• If unsure about an answer to a patient's question, redirect them to the doctor to maintain trust and avoid providing incorrect information.
• If sure about the answer, feel free to explain it to the patient.
• Alternative approach: provide a generalized explanation, citing examples from the patient's condition.

SOAP (Subjective, Objective, Assessment, Plan)

Subjective

• Refers to the patient's report during their therapy session.
• Critical for person injury (PI) patients, as charts may be audited in court.
• Guidelines for obtaining an accurate subjective:
  • Write down the chief complaint, its intensity, and any changes since the last visit.
  • Note what the pain is preventing the patient from doing.
  • Record pain intensity without using numbers:
    • Mild: 1-2/10
    • Moderate: 3-5/10
    • Severe: 6-10/10
  • Focus on ADL, pain, and suffering.
  • Avoid statements like "Patient feels good" or "Patient had one headache today". Instead, justify the need for care.

Objective

• Refers to what the provider observes.
• Copy & paste from the Pertinent Findings listed in the Diagnosis and Plan chart.

Assessment

• Refers to the diagnosis.
• Copy & paste the bullet points listed in the Diagnosis section in the Diagnosis and Plan chart.

Plan

• Refers to the specific treatments done during the therapy session.
• Importance of increasing exercise difficulty from one session to the next to challenge the patient.

Patient Questions

• If unsure about an answer to a patient's question, redirect them to the doctor to maintain trust and avoid providing incorrect information.
• If sure about the answer, feel free to explain it to the patient.
• Alternative approach: provide a generalized explanation, citing examples from the patient's condition.

SOAP (Subjective, Objective, Assessment, Plan)

Subjective

• Refers to the patient's report during their therapy session.
• Critical for person injury (PI) patients, as charts may be audited in court.
• Guidelines for obtaining an accurate subjective:
  • Write down the chief complaint, its intensity, and any changes since the last visit.
  • Note what the pain is preventing the patient from doing.
  • Record pain intensity without using numbers:
    • Mild: 1-2/10
    • Moderate: 3-5/10
    • Severe: 6-10/10
  • Focus on ADL, pain, and suffering.
  • Avoid statements like "Patient feels good" or "Patient had one headache today". Instead, justify the need for care.

Objective

• Refers to what the provider observes.
• Copy & paste from the Pertinent Findings listed in the Diagnosis and Plan chart.

Assessment

• Refers to the diagnosis.
• Copy & paste the bullet points listed in the Diagnosis section in the Diagnosis and Plan chart.

Plan

• Refers to the specific treatments done during the therapy session.
• Importance of increasing exercise difficulty from one session to the next to challenge the patient.

Learn how to respond to patients' questions when you're unsure or don't know the answer, and how to maintain their trust.