S.O.A.P Notes pointers.
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SUBJECTIVE
Information gathered directly from the client, including their own description of symptoms, history, and concerns.
What to Record:
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Presenting Complaint
“What brings you in today?”
▸ Describe the main issue in the client’s own words.
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History of Presenting Complaint
▸ When did it start?
▸ Was there an injury or trigger?
▸ Has it worsened or improved over time?
▸ Is it constant or intermittent?
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Pain Description
▸ Location, type (sharp, dull, ache, burning), intensity (0–10 scale), duration.
▸ What aggravates or relieves it?
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Functional Limitations
▸ Activities affected (e.g., walking, driving, work, sleep).
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Medical & Treatment History
▸ Past injuries, surgeries, chronic illnesses.
▸ Current medications, past treatments (physio, chiro, massage, etc.).
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Lifestyle Factors
▸ Occupation, posture habits, stress, activity level.
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Red Flags
▸ Ask about signs of serious pathology: night pain, weight loss, numbness, incontinence, dizziness, etc.
Your professional observations and test results gathered through assessment techniques.
What to Include:
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Observation and Postural Assessment
▸ Check for postural deviations: forward head, shoulder elevation, pelvic tilt, knee valgus, foot pronation, etc.
▸ Note symmetry, muscle bulk, and spinal curves.
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Palpation Findings
▸ Muscle tone, tenderness, trigger points, swelling, texture changes.
▸ Temperature, skin texture, fascial restriction.
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Range of Motion (ROM) Tests
▸ Active and passive ROM of affected joints.
▸ Document limitations, compensations, or pain.
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Orthopedic Tests
▸ Relevant tests for the region (e.g., Hawkins-Kennedy for shoulder impingement).
▸ Note positive or negative results.
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Neurological Findings (if needed)
▸ Reflexes, strength testing, dermatomal sensation, if red flags suggest neural involvement.
Your clinical interpretation based on subjective and objective findings. This is your working hypothesis.
What to Include:
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Summary of Findings
▸ Connect symptoms with patterns (e.g., postural overload, myofascial restriction, overuse injury).
▸ Identify likely cause or contributing factors (e.g., poor desk posture, repetitive strain, compensation).
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Clinical Impression / Provisional Diagnosis
▸ E.g., "Likely rotator cuff strain with secondary upper trapezius overactivity."
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Differential Diagnosis
▸ List possible other conditions you’ve ruled out through observation and testing.
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Functional Impact
▸ Summarize how the condition is affecting their daily life or work.
Your treatment approach and goals moving forward, tailored to the client’s presentation and goals.
What to Include:
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Immediate Treatment Plan (Today’s Treatment)
▸ Techniques used: deep tissue, myofascial release, trigger point therapy, MET, joint mobilisations, etc.
▸ Areas treated and response to treatment.
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Short-Term Goals (1–2 weeks)
▸ Reduce pain, improve ROM, decrease muscle tension, restore function.
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Long-Term Goals (2–6 weeks+)
▸ Address postural imbalance, strengthen weak areas, prevent recurrence.
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Home Care / Client Education
▸ Stretches, postural advice, self-massage, ergonomic tips, ice/heat, activity modification.
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Treatment Frequency Recommendation
▸ E.g., “2 sessions per week for 2 weeks, then reassess.”
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Referral (if required)
▸ GP, physio, osteo, chiro, or imaging if red flags or no improvement.