Question

Organize the following information so that it is clear, concise, and suitable for entry into the medical record. What statements will be S, O, A and P?

You have been treating a patient with plantar fasciitis, providing ultrasound, soft tissue massage, and stretching. On the third visit, the patient indicates his pain in the morning has decreased from five out of then to three out of ten. His active and passive dorsiflexion range of motion have increased by five degrees. During gait, he has increased his stance time on the involved extremity.

Girth at the right knee joint line was 34 cm, 2 inches above the right knee joint line was 38 cm, 4 inches above the right knee joint line was 42 cm, and 4 inches below was 35.5 cm. Active flexion was 120 degrees. The patient lacks 20 degrees of active extension. Hip and ankle active range of motion were within normal limits. Strength for the quadriceps muscle was three minus out of five and for the hamstring was three minus out of five. The patient walks independently with crutches, weight bearing as much as he can tolerate on the involved extremity for one hundred feet.

Answer 1

The SOAP note (an acronym for subjective, objective, assessment, and plan)  is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.

The four components of a SOAP note are Subjective, Objective, Assessment, and Plan.

Chief complains: are patient is suffering from plantar fasciitis. The patient indicates his pain in the morning has decreased from five out of then to three out of ten. During gait, he has increased his stance time on the involved extremity.

Physical Examination:

Musculoskeletal: Girth at the right knee joint line was 34 cm, 2 inches above the right knee joint line was 38 cm, 4 inches above the right knee joint line was 42 cm, and 4 inches below was 35.5 cm. Active flexion was 120 degrees. The patient lacks 20 degrees of active extension. Hip and ankle active range of motion were within normal limits. Strength for the quadriceps muscle was three minus out of five and for the hamstring was three minus out of five.

DIAGNOSTIC DATA: Ultrasound of the affected extremity.

DIAGNOSIS: Plantar fasciitis

PLAN:We have been treating the patient with soft tissue massage and stretching. As of now The patient walks independently with crutches, weight bearing as much as he can tolerate on the involved extremity for one hundred feet.