Introduction

From September 24, 2015 until January 5, 2016, I was able to shadow Matthew Lopez, DPT (physical

therapist) at the Wexner Medical Center. Because I want to become a physical therapist and will be

attending OSU majoring in Health Sciences, Matt became a valuable resource to me regarding the day to

day activities a physical therapist performs. In our discussions, Matt stressed the importance of clinical

knowledge since that drives how the patient recovers. The other thing he stressed was the importance

of documentation. He explained that clinical documentation is the single most important thing a

therapist needs to know after clinical knowledge. Documentation provides proof of treatment, an

explanation to insurance companies, and evidence of progress, plateaus, or regression. As Matt would

say, “If it isn’t documented, it didn’t happen”. This is mantra that all therapists live by.

The most common form of documentation at OSU is the use of a SOAP note. SOAPs are a four part

narrative that includes Subjective, Objective, Assessment, and Plan. In the Subjective section, the

therapists records how the patient is feeling, and messages from the referring doctor, or other items

that did not result from objective measurement and data. When specific measurements and data are

taken, those data points are reported in the Objective section. The Assessment section explains how and

why the measurements and data from the Objection section are important. Finally the Plan section

explains what will happen next; begin treatment, continue treatment, implement new goals, or

discharge from treatment. Because documentation is so important, I chose to write SOAP notes for the

patient I followed in order to get a head start on learning how to document what happens in a

treatment session.

For a little over 3 months I followed the recovery of a 46 year old woman who just had shoulder surgery.

These notes progress from her first visit (September 29, 2015) through her discharge (January 5, 2016).

After each visit I was able to discuss with Matt what information should go in my SOAP note. He

provided me with guidance and feedback – and many medical term definitions.