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Hi I'm Bob Serum physical therapy and physical therapy there we are the most famous physical therapist on the internet no opinion of course Bob Brad we had a request right as you know we've got a number of students that watch our videos and this particular student says are you going to do one on soap notes alright and both you and me that it was a little troublesome that I was for me sure how do you do a small start yeah, and it's not the worst for people who don't you know darn students they can see how we document exactly about people and these soap notes are something that nurses use OT's PT's a lot of people in the health field and what do they mean by soap we're talking about subjective s objective all an is your assessment and P is the plan now I'm not going to go through this a lot of detail Bob, but these are things that helped me out when I started this to make them efficient and a nice clean note can you read this okay Land by the way at the right angle okay yeah it's my writing it's not very clear that's why I dictate everything, so subjective is first right, and I always start out with this sentence well it depends on the general patient is a pleasant 41-year-old male with complaints of low back pain it puts it out right away you have a picture of whom this person is sometimes I'll put in there if their slender obese or something of that name right, and you got the age in there so they you right away know where your you are you know demographically wise exactly, and we know the basic complaint is low back pain, and we're not going to get specific yet and then my second set of they're unpleasant you put unpleasant yes you better believe I do all right it's important to know if the therapists next you know for sure it's the next it kind of prepared for them may be agitated you might put yeah right descriptive be professional yeah the next sentence will be protective you know the next sentence I go to the primary part of subjective primary complaint of low back pain with sitting okay and there may be some other things but that's so you get right to the point, and then you can add in some fillers if you want to sure this is the way I do it Bob Dylan how you like to do your curve then objective and this varies from therapist to therapist, but it's always things you can measure very objective things like range of motion you can measure if there's point tenderness at what location is a l4 l5 you know in the sacral area euro test if you're going to do some euro tests with your reflex hammer manual muscle testing you get some muscle grades four out of five three out of five other special tests you got any other ones that know that covers most of them the objective test you're going to do especially with back pain now if someone else had a balance problem then you'd be doing some balances exact like that right depending on the problem and then the assessment part and this is where the first thing I always write down our symptoms are consistent...
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