Patient records
(SdotOdotAdotP)

patient records

Keeping your S.O.A.P notes correctly is vital to the work of any physio.

Analysis notes

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Subjective assessment

Record what the patient tells you

patient assessment

Red flags red flags

Red flags are warning signs or symptoms that suggest a serious underlying disease

Please seek medical help if any of the above apply

 
 

Analysis notes

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S

S.O.A.P. notes make your assessment and treatment logical and keep your records clear.

S = Subjective; what the patient tells you i.e. symptoms you cannot see such as pain or how they are feeling, and vital details about family or living conditions
O = Objective; what you can see i.e. signs such as heat, redness, range of movement and what treatment you might give such as which exercise, or how many and how often
A = Analysis: what you question may or may not be happening, so reasoning through a problem such as progress the patient is making comes in here
P = Plan: what you want to do next time, such as add a new treatment as patient progresses

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O

Example of record form

Hover over the blue numbers to see its relevant note

READY?

When you are ready, please proceed to the assessment of your patient.