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Physiotherapy student SOAP notes example
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SOAP notes example for Physiotherapy student on placement. Note taking can be challenging for students and having an example to refer to can facilitate to familiarise with notes taking.

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  • March 31, 2021
  • 3
  • 2020/2021
  • Other
  • Unknown

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Physiotherapy at: Time of assessment

S: Patient consented to assessment and treatment. History and news chart viewed. Patient in good spirit
and reports to feel well this morning. Patient was assessed by OT this morning. Patient reports that stiff
L shoulder and R knee pain are both longstanding problems.


O: Obs stable.

Patient asleep lying on bed on arrival, catheter in situ. R knee hot at touch and swelling, dull pain
reported when WB. Left heel wound dressed with tegaderm foam.
NEWS: (0)




Shoulder assessment:


AROM:
Upper limbs:

RUL: full functional AROM


-shoulder flexion: 90* MP 5/5
-shoulder abduction: 90* MP 5/5

-shoulder external rotation: 80* MP 5/5

-shoulder internal rotation: 50* 4/5

-elbow flexion: full AROM, MP 5/5


LUL: limited functional AROM


-shoulder flexion: 70* MP 4/5
-shoulder abduction: 60* MP 4/5

-shoulder external rotation: 45* MP 4/5

-shoulder internal rotation: 40* 4/5
-elbow flexion: full AROM, MP 5/5




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