Evaluation SOAP Notes. HOPS H istory: a series of questions asked to determine nature and location...
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Transcript of Evaluation SOAP Notes. HOPS H istory: a series of questions asked to determine nature and location...
HOPS
History: a series of questions asked to determine nature and location of injury
Observation: A visual examination of the injury
Palpation: A hands-on approach where examiner feels for deformity or other abnormal findings
Stress tests: A series of tests to check range of motion and degree of function of tissues at a joint
SOAP NoteSubjective:
Detailed information about the history of injury and athlete; chief complaints, sign, and symptoms
Objective: Information that is record of test measurements;
data gained from inspectionAssessment:
Identification of problem; determine injury; severity of injury
Plan of Action: Treatment; Rehabilitation; Referrals
SOAP Note Writing Format
Name of Athlete:Date of Examination:Date of Injury:Place of Injury:S:O:A:P:
SOAP
Subjective Findings
• Subjective is the oral section of the evaluation; what the patient or witnesses tell you.
• Ask these questions:– Was there a previous injury?– How did it happen?– When did it happen?– What did you feel?– How do you feel?– What is the type of pain?– Where does it hurt?– Did it make a sound?
* Ask for a witness if the person is incapable of answering
Objective Findings• Objective is the visual and the hands-on part of the evaluation.• Look for the following:
– Swelling– Deformity-protrusions– Ecchymosis-Discoloration– Symmetry– Gait-Walk– Scars– Facial expressions– Bleeding– Depressions– ROM– Stress Test Results
Objective Findings
• Perform Palpations• Check anatomical structures to determine
points of pain• Check for abnormalities• Preform special test or stress tests to assess
severity
Active Listening Skills
• 1. Face the speaker—lean slightly forward• 2. Maintain eye contact• 3. Minimize external/internal distractions• 4. Respond appropriately• 5. Focus solely on what the speaker is saying• 6. Keep an open mind• 7. Avoid giving advice until you have completely
evaluated injury• 8. Don’t interrupt• 9. Stay engaged in the interview
Extras!
• Review your notes with the athlete after you have completed your evaluation!
• The athlete’s well-being WILL depend on the accuracy and thoroughness of your Soap! Ask probing questions and record accurately!
• This is a medical and legal document and will be used in the court of law if needed.
Stress Tests of the Ankle/Foot
• Anterior Drawer• Talar Tilt• Kleiger’s• Tap/Bump Test• Squeeze Test• Thompson’s Test• Homan’s Sign
Anterior Drawer
• Steps:– Athlete is sitting over the edge of the table with the knee
bent– Examiner stabilizes the lower leg with one hand (around the
tibia/ fibula) & cups the calcaneus with the forearm supporting the foot in slight plantar flexion (~ 20° ) and slight inversion (few degrees)
– Examiner draws the calcaneus & talus anteriorly and slightly medially
• Tests For:– ATF sprain – positive is pain and laxity over the ATF ligament.
Talar Tilt
• Steps:– Athlete is sitting with his/her legs over the edge of the table– Examiner grasps the calcaneus with one hand & stabilizes the lower
leg with the other hand– Examiner provides inversion stress rolling the calcaneus inward
while the ankle is in neutral– Examiner provides an inversion stress by rolling the calcaneus
inward while the ankle is in the plantar flexed position– Examiner provides an eversion stress rolling the calcaneus outward
while the ankle is neutral• Test For:
– Inversion Stress: CF ligament and possibly the ATF and PTF.– Eversion Stress: Deltoid ligament
Kleiger’s (External Rotation) Test
• Steps:– Athlete is sitting with his/her legs over the edge of the
table– Examiner stabilizes the lower leg with one hand– Examiner grasps the medial aspect of the foot while
supporting the ankle in neutral and externally rotates– Examiner dorsiflexes and externally rotates the foot
• Tests For:– DF: test for syndesmosis involvement– Neutral: test for injury to the deltoids
Thompsons Test
• Steps:– Athlete is prone with his/her knee extended– Examiner squeezes the calf musculature while
observing for ankle plantar flexion• Tests For:
– Ruptured Achilles Tendon: positive test is the ankle will not PF when squeezed
Tap Test/Bump Test
• Steps:– Athlete is sitting or lying supine, with the involved
foot off the end of the table & the knee straight– Examiner stabilizes the lower leg with one hand &
bumps the calcaneus with the other hand– Examiner bumps the calcaneus 2–3 times with
progressively more force• Test For:
– Fractures: pain emanating from the fx of calcaneus, talus, tibia, or fibula
Squeeze Test/Compression
• Steps:– Athlete is sitting or lying with his/her knee extended– Examiner cups his/her hands behind the tibia &
fibula, away from the site of pain– Examiner compresses the tibia & fibula, gradually
adding more pressure• Test For:
– Fracture: pain is elicited in the area away from the compression
Homan’s Sign
• Steps– Athlete is sitting or supine with the knee extended– Examiner passively dorsiflexes the foot while knee
is extended– Examiner squeezes the calf muscles
• Test For:– DVT (Deep Vein Thrombosis): Pain in the calf
Rehabilitation Phases
• There are 6 phases of the rehabilitation process.
• The different phases can go on concurrently, however you must be able to complete the prior phase to add in the next phase.
• Therapeutic: is the healing action; of or relating to the treatment of disease or disorders by remedial agents or methods
Phase I: Pain Management
• Time immediately following injury or surgery which movement is limited in the affected part to ease pain
• How To: – Pain control - Medication– Control inflammation– RICE
Phase II: ROM
• Time when therapeutic action is initiated including joint range-of-motion, mobility and flexibility exercises
• How To:– PROM- passive rom– AAROM- active assisted rom– AROM- active rom– Flexibility
Phase III: Proprioception
• The phase where the body relearns the ability to sense the position of its limbs during movement and in space; includes balance and coordination
• How To:– Balance exercises– Coordination exercises
Phase IV: Resistive Training
• The phase to increase muscular strength• How To:
– Emphasize the injured area, but maintain whole body strength
Phase V: Endurance
• This phase is for both the cardiovascular and muscle systems to be able to perform work over a period of time
• How To:– High amount of repetitions with low weight is
muscular endurance– Full-body cardiovascular endurance