The therapist notes 'left upper trapezius hypertonic on palpation; cervical rotation left limited to about 45 degrees.' Which SOAP section is this?
- Subjective
- Plan
- Objective
- Assessment
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C. Objective
Findings the therapist observes or measures, such as palpation, posture and range of motion, go under Objective. Assessment is tempting because of the word, but in a SOAP note it records the response to treatment and the therapist's summary.
Reference: MBLEx content outline: Client Assessment, Reassessment and Treatment Planning; documentation, SOAP notes
Where in a SOAP note is 'Return in one week; client to do daily neck stretches at home' recorded?
- Plan
- Objective
- Assessment
- Subjective
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A. Plan
The Plan section covers future treatment, frequency and self-care suggestions. The Assessment section records what changed as a result of today's session, not what happens next.
Reference: MBLEx content outline: Client Assessment, Reassessment and Treatment Planning; documentation, SOAP notes
In passive range of motion testing, who moves the joint?
- The therapist, while the client stays relaxed
- The client and therapist, moving together
- The client, against the therapist's resistance
- The client, with no help from the therapist
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A. The therapist, while the client stays relaxed
In passive range of motion the therapist moves the relaxed client's joint, which tests inert structures such as the capsule and ligaments and the end feel. Active range of motion is the client moving unaided.
Reference: MBLEx content outline: Client Assessment, Reassessment and Treatment Planning; range of motion assessment