SOAP Natisa Hall-Joseph SOAP Date Heure 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Treatment Intervention Perform Evaluation Quatitative Qualitative Self Word Treatment Cox Lumbar Cox Cervical Cox Thoracic Diversified Other Dictation Notes General Evaluation Quantitative Rating Timing beginning of treatment end of treatment post treatment Improvement improved stable worse Symptoms changes since last treatment ? -30%-25%-20%-15%-10%-5%0%5%10%15%20%25%30%35%40%45%50%55%60%65%75%80%85%90%95%100% Duration of symptoms post treatment? 12345678910 Timing hours days Pain Transition FROM ? 012345678910 Pain Transition TO 012345678910 Symptoms level now ? 0 1 2 3 4 5 6 7 8 9 10 Symptoms level in the last 48 hours ? 0 1 2 3 4 5 6 7 8 9 10 Improvement since beginning ? 0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100% Improvement quality life ? 0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100% How far are you from a normal condition ? 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Notes Quantitative Evaluation plus1 Add minus1 Remove Evaluation Qualitative ADL Factors provocative easing Regions spine neck head upper limb anterior trunk abdomen posterior trunk back pelvic girddle lower limb nodes Sub Regions Sub Sub Regions Provocative/Ease Categories seated erect sleep ROM movements Provocative/Ease Factors Seansation Category pain sensation locomotion CNS cephalic vascular glandular Sensation Factor Notes Qualitative Evaluation plus1 Add minus1 Remove Lumbar Cox Treatment Section Lumbar Treatment Upper Lumbar Mid Lumbar Lower Lumbar Sacroiliac Sacrum PSIS L1 L2 L3 L4 L5 Contact Laterality R L Position Prone Supine Side Body Strap Ankle Straps No Ankle Straps Movement axial flexion lateral flexion R lateral flexion L rotation extension drop Distance .5 1 1.5 2.0 2.5 Heure min 2.5 5 7.5 10 12.5 Quatities 1 2 3 4 5 6 Notes Treatment Lumbar plus1 Add minus1 Remove Cervical Cox Treatment Section Cervical Treatment Upper Cervical Mid Cervical Lower Cervical Upper Thoracic Occ C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 Interscapular Trapezius Contact Laterality R L Manual Contact proximal phalenges carpals lateral index 1-2-3-phalenges Position Prone Supine Neck Straps Movement axial flexion lateral flexion R lateral flexion L rotation R rotation L extension Dictation Notes Treatment Cervical plus1 Add minus1 Remove Thoracic Cox Treatment Thoracic Treatment Upper Thoracic Mid Thoracic Lower Thoracic T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 Position Prone Supine Side Ankle Straps No Ankle Straps Contact Laterality R L Movement Axial Distance .5 1 1.5 2.0 2.5 Heure min 2.5 5 7.5 10 12.5 Quatities 1 2 3 4 5 6 Notes Treatment Thoracic plus1 Add minus1 Remove Diversified Treatment Cervical Treatment Upper Cervical Mid Cervical Lower Cervical Occ C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 SI Position Prone Supine Side Contact Laterality R L Cavitation yes no Notes Treatment Diversified plus1 Add minus1 Remove Other Treatment Therapies TP Therapy Regions abdomen anterior trunk back head lower limb neck nodes pelvic girddle posterior trunk spine upper limb Sub Regions Sub Sub Regions Contact Laterality R L Notes Treatment Other plus1 Add minus1 Remove Evaluation Self Satisfaction about your progress ? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A What can you do to improve? Exercise Walk Swim Gym Sit less Stand more OtherOther Notes Evaluation Qualitative Evaluation Words Three words describe your condition (positive)? accalmie agréablement surpris(e) amélioration apaisement aucun mal aucune douleur beaucoup moins bien dormie bien dormir bonne nouvelle bonne voie changement confort content(e) de plus en plus solide dégagé détendu diminuer disparaît (disparu) dissipée enchanter encourager énergie espoir euphorie évolution exercices faible intensité fait du bien fluide heureux(se) intermittent je me sens bien mieux mobilité modérée moins forte moins intense occasionnellement optimiste pas de crise plus de force relâchement relax renforcement satisfait soulagée stables Three words describe your condition (negative)? accentuée aiguë augmentation baisse énergie barrée blocage brûlement case de départ cauchemar chronique compressée constant contractée courbaturée crampes crise décroissance dégradation déséquilibrer désespérer détresse difficile difficulté douleur(eux) élancement empirée endolori engourdissement fatigue persiste fragile glace immobile incapable inconfort inconfortable instable insupportable intense intensifiée j’ai mal lourdeur manque de sommeil médication moins de force nausée ne cesse d’augmenter pas dormi peur pincement pire pression raideur rechute régression relaxant musculaire retombée serrement spasme tension tiraillement toujours mal très difficile Notes Evaluation Words Rehab arrowup6 Ergonomics Pilllows Chair Computer Screen Lifting Sleeping Kyphosis Towel Lumbar Support OtherOther Exercises Ab Straps Swimming Gym Stretching Stair Climbing Sit Stand OtherOther Gym Exercises Lats pull down Chin Ups Ankle (dorsiflexion) Trap Raises Chin Ups OtherOther Stretches Hamstring – Under Table Hanstring – On top of Desk Gluteal – Figure 4 Supine Gluteal – On Top Table Gluteal – Against the Wall Ball OtherOther Notes Rehab Medication arrowup6 Are you medicated presently? yes no Medication Status Diminished Same Augmentation Number of medication taken 0123456789101112131415 Notes Medication Soumettre If you are human, leave this field blank.
