SOAP is the abbreviation of English initials, and these four letters represent four parts of patient information respectively. S stands for subjective data, O stands for objective data, A stands for evaluation and P stands for plan.
The subjective data of is the same as POMR. "S" should include all the information obtained by the therapist from the patient about his injury or problem, and the information provided by the patient's family or caregivers should also be included in the information of subjective data.
An evaluation and an explanation and impression of the patient's problem are included in "A".
Brief introduction of soap related content:
"O" should include relevant examinations and tests, patients' recent functional status and the treatment measures they received that day. Physical therapy should include daily treatment, such as strength training and activity training, cooperation with other departments and rehabilitation education for patients and their families.
Soap This is an internationally recognized daily medical record format. Originated from 1964, it was first proposed by Lawrence Wade, a doctor and educator at Casey Reserve University in the United States. He expects to "adopt a standard recording format, with the purpose of finding patients' problems and trying to solve them, so as to record patients' health information. This method is easy to master and understand, and can promote medical staff to continuously evaluate patients and then modify the diagnosis and treatment plan. "