Business of OMT:The Osteopathic SOAP note

PdTF III CurriculumKatie Dickey OMS III PdTF IV

Principles of Instructional Designkdickey@westernu.edu

Objectives

• PdTF III will be able to accurately describe the four sections of a SOAP note by the end of the lecture.

• PdTF III will be able to accurately document structural exam findings on an osteopathic SOAP note

• PdTF III will be able to correctly document an assessment and plan for an osteopathic SOAP note by the end of the lecture.

SOAP

• Subjective

• Objective

• Assessment

• Plan

SOAP

• Subjective– Patient history: OPQRST– Medications/Allergies– Past Medical History– Past Surgical History– Family History– Social History– Review of Systems

• Objective• Assessment• Plan

SOAP

• Subjective• Objective– Vital Signs– Physical Exam– Osteopathic Structural Exam• Specific exam findings.

• Assessment• Plan

SOAP

• Subjective• Objective• Assessment– Diagnosis– Ie. Somatic Dysfunction & what regions

• Plan

SOAP

• Subjective• Objective• Assessment• Plan – Treatment– Ie. What OMT techniques you used, follow-up,

lifestyle changes recommended

• Insert image of soap note.

Any questions?