Get AAO Outpatient Osteopathic SOAP Note Follow-Up Form 2002-2024

The osteopathic structural exam (AKA MSK exam) is reported in the medical record as a narrative. You will note your findings of tissue texture abnormalities, asymmetries of structure, restriction of motion and tenderness (TART). You should include specific segmental dysfunction in your note when there is one.

In the outpatient clinic, SOAP is the traditional note structure: S ubjective, O bjective, A ssessment, P lan. Although electronic health records may structure notes differently, this is still the information that you would enter at a problem focused or chronic disease management visit.

A SOAP note is a written document that a healthcare professional creates to describe a session with a patient/client. The information included is: Subjective, Objective, Assessment, Plan (SOAP). Many fields rely on SOAP notes to transfer information between professionals.

SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them.

The Outpatient Osteopathic SOAP Note Form Series is a four-page note that is ideal for use as a new patient initial exam for a general medical visit. It contains a Health Summary page for a detailed history and plenty of space to write exam findings in addition to the somatic dysfunction table.

Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data.

When making subjective statements, include pertinent evidence. For example: “Client appears nervous as evidenced by fidgeting of hands, not maintaining eye-contact, and shortness of breath during our session.”

The osteopathic structural exam (AKA MSK exam) is reported in the medical record as a narrative. You will note your findings of tissue texture abnormalities, asymmetries of structure, restriction of motion and tenderness (TART). You should include specific segmental dysfunction in your note when there is one.

In the outpatient clinic, SOAP is the traditional note structure: S ubjective, O bjective, A ssessment, P lan. Although electronic health records may structure notes differently, this is still the information that you would enter at a problem focused or chronic disease management visit.

A SOAP note is a written document that a healthcare professional creates to describe a session with a patient/client. The information included is: Subjective, Objective, Assessment, Plan (SOAP). Many fields rely on SOAP notes to transfer information between professionals.

SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them.

The Outpatient Osteopathic SOAP Note Form Series is a four-page note that is ideal for use as a new patient initial exam for a general medical visit. It contains a Health Summary page for a detailed history and plenty of space to write exam findings in addition to the somatic dysfunction table.

Objective means that it is measurable and observable. In this section, you will report anything you and the client did; scores for screenings, evaluations, and assessments; and anything you observed. The O section is for facts and data.

When making subjective statements, include pertinent evidence. For example: “Client appears nervous as evidenced by fidgeting of hands, not maintaining eye-contact, and shortness of breath during our session.”