How to Document a Sports Physical with a SOAP Note

What should be included in the Subjective section?

In the Subjective section, record the athlete's personal and medical history. Ask about any past injuries, surgeries, or ongoing issues. Note any symptoms they report, even if they seem minor.

• Chief complaint (if any)
• History of present illness or injury
• Past medical history, including surgeries
• Family history of medical conditions
• Social history, including sports participation

How do I fill out the Objective section?

The Objective section is where you document your physical exam findings. Include vital signs like heart rate and blood pressure. Perform a thorough musculoskeletal exam, checking for joint stability, muscle strength, and flexibility. Also, assess cardiovascular, respiratory, and neurological systems.

• Vital signs
• General appearance
• Musculoskeletal exam
• Cardiovascular assessment
• Respiratory assessment
• Neurological assessment

What goes into the Assessment part?

The Assessment section is where you provide a summary of your findings. Identify any issues or conditions that might affect the athlete's ability to participate in sports. You might note something like "no contraindications for participation" or specify any limitations.

Example: "Healthy 16-year-old male with no contraindications for football."

What should be included in the Plan section?

The Plan outlines the next steps. If the athlete is cleared for sports, note that here. If there are any concerns, describe the follow-up actions, such as referrals to specialists or specific exercises for injury prevention.

• Clearance status
• Recommendations for follow-up
• Preventive measures or exercises
• Referrals to specialists if needed

Can you provide a real-world example of a SOAP note for a sports physical?

Sure, here's a simple example:

Subjective: 17-year-old female soccer player, no current complaints. History of ankle sprain last year, fully healed. No other significant medical history.

Objective: Vitals: BP 110/70, HR 72. Musculoskeletal: Full range of motion in all joints. Cardiovascular: Normal heart sounds. Respiratory: Clear lungs. Neurological: Normal reflexes.

Assessment: Healthy adolescent with no contraindications for soccer.

Plan: Cleared for participation. Recommend ankle strengthening exercises to prevent future sprains.