How to Document a Sports Physical with a SOAP Note

What should go in the Subjective section?

In the Subjective section, you'll record the athlete's own words about their health. Ask about past medical history, any previous injuries, and current symptoms. This is also where you note family medical history and any medications or supplements the athlete is taking.

• Example: "16-year-old male reports no current pain but has a history of a sprained ankle last year. No family history of heart disease."

What do you include in the Objective section?

The Objective section includes measurable data from your physical exam. Record vital signs like blood pressure and heart rate. Include findings from your musculoskeletal, cardiovascular, and respiratory exams. Note any abnormalities or areas of concern.

• Example: "Blood pressure 120/80, pulse 70 bpm. Normal range of motion in all joints, no swelling or tenderness. Clear lung sounds."

How do you write the Assessment?

In the Assessment, summarize your clinical impressions. If the athlete is healthy, state that. If there are concerns, note them here. Include any diagnoses or considerations for further testing.

• Example: "Healthy adolescent male, cleared for sports. Consider follow-up for previous ankle injury if symptoms recur."

What is the Plan section for?

The Plan outlines your recommendations. Include any advice on conditioning, injury prevention, or follow-up care. If the athlete needs referrals or additional tests, note them here.

• Example: "Recommend daily stretching and strengthening exercises for ankle. Follow up in 6 months or if symptoms develop."

How do you ensure thorough documentation?

Thorough documentation is key. Make sure to be clear and concise. Use medical terms accurately but keep it simple. Double-check for completeness and accuracy. Remember, your SOAP note should be easy for another healthcare professional to understand.

• Review each section for completeness.
• Ensure clarity and conciseness.
• Use accurate medical terminology.