Taking SOAP Notes
Ex Rx: Clean up your client documentation using a system favored by the medical community.
Personal training is evolving at an unprecedented rate, and keeping pace requires developing innovative approaches to professional skills. Documenting client progress is one such skill. Emerging training models require more sophisticated methods of documentation. Today, trainers working with special populations often work as part of a multidisciplinary team that may include physical therapists, nutritionists and massage therapists, all of whom have their own treatment goals. Plus, some new business models use a team approach in working with each client: a client may not have the same trainer on Friday that he had on Monday and Wednesday.
How can you as a personal trainer communicate with a team of trainers working with the same client, maintain continuity of care with allied medical professionals and accurately manage and document client progress? Discover a documentation process called SOAP noting (Subjective, Objective, Assessment and Plan) and learn the basics about modifying it for the fitness industry.
What Is SOAP Noting?
This simple yet comprehensive technique was developed for medical and mental healthcare providers in the late 1960s. They used SOAP notes to organize symptoms, observations, assessments and the treatment plan. The ultimate goal of the system was to improve communication among all medical disciplines caring for a patient.
“SOAP notes have been used by therapists for decades,” says Ann Zylstra, lead physical therapist at Evergreen Hospital in Kirkland, Washington. She adds that personal trainers who use SOAP notes “facilitate the integration of personal trainers into a client healthcare team.”
According to the American College of Sports Medicine (ACSM), “The major benefit of this technique is that it organizes extremely complex problems into simpler parts that are more easily tracked and solved” (Durstine & Moore 2003).
Why Use SOAP Noting?
SOAP noting offers you the following benefits as a personal trainer:
- It provides a tracking technique for compiling relevant information used to recognize negative and positive behavior patterns in a client.
- It helps you identify obstacles and develop strategies to assist the client in achieving goals.
- It offers concrete evidence of progress that you can show the client. Using and reviewing the notes with him or her also demonstrates professionalism, builds trust and credibility and enhances client compliance and retention.
Dave Johnson, president of Elite Fitness in Bellevue, Washington, likes this note-taking system because it “provides us a tool for managing the progress of all our clients, not just special populations,” he says. “We use these notes to track injury reconditioning, dietary issues, motivation level or any factor directly related to the client’s objective.”
Melissa Pei, DPT, physical therapist at Evergreen Hospital in Kirkland, Washington, thinks that personal trainers should adopt this method. “SOAP noting provides a standardized method for documenting client progress that is simple, concise and compatible with many allied medical professions,” she says. “Today there is little or no direct communication between physical therapists and personal trainers. SOAP notes are a simple, effective vehicle to facilitate dialogue in jointly addressing patient/client needs.”
How to SOAP Note
What type of information should you, as a personal trainer, include in SOAP notes?
Subjective. In the “Subjective” section, include client responses to your questions regarding exercise adherence, changes in functional abilities, health status and follow-up activities. Write down answers using the client’s own words. For example, the client might say, “I’m out of breath when I climb the stairs at home” or “I want to be able to go for walks with my grandson without tiring so quickly.” Include client feedback regarding the exercise program; for instance, “I felt sore for 3 days after our last workout together.” Also integrate your subjective observations of the client, such as “Client is limping” or “Client is highly motivated.”
Objective. In the “Objective” section, note new data collected during the training session. Data may include results of any follow-up fitness tests performed (body composition, muscular strength and endurance, flexibility or cardiorespiratory). Record such things as the client’s clinically provided blood lipid analysis, and note new medications, changes to current ones and potential affects of the medications on exercise response (e.g., hypotension, increased heart rate, muscle cramping, etc.). Track changes self-reported by the client, such as daily blood pressure monitoring for a hypertensive client or blood sugar readings provided by a diabetic client. Always indicate that this data is “self-reported.” Example: “Client’s self-reported glucose today was 110, an hour prior to exercise.” Highlight general changes to the exercise program, detailing these in depth on the client’s exercise card.
Assessment. In the “Assessment” section, document noteworthy changes you see in the client’s performance. You might write “Client has greater difficulty balancing on his left foot compared with his right foot” or “Client no longer has tight hamstring muscles after stretching regularly for 3 weeks.” Record any new information that healthcare providers or fellow trainers pass along to you. Be sure to include any information from your client’s primary care provider about specific changes in the client’s medical status as they relate to health and fitness goals. An example might be “Diagnosed with type 2 diabetes, 01/17/08.” Also indicate any exercise contraindications that a physical therapist or physiatrist communicates to you; for instance, “Client should not perform open-chain weighted knee extension exercises.”
Plan. After you have gathered the subjective, objective and assessment information, briefly outline revisions or adjustments to the exercise program design in the “Plan” section. Note adjustments for energy expenditure, mode of exercise and how you will accommodate exercise contraindications. You might write “Client’s physical therapist communicated that client may progress from open-chain to closed-chain exercises for the lower body” or “Client is advised to do only low-impact aerobic activities to minimize aggravation to left ankle injury.”
Also use this section to record ongoing notes on wellness coaching; for example, “It was recommended that the client avoid eating while watching television or when emotionally upset.” Note referrals here as well: “Client is being referred to a registered dietitian for menu planning options.”
See the “SOAP Note Example” sidebar for more details.
Scope of Practice
As personal trainers continue to work more closely with the healthcare community, it is important that they stay within their scope of practice. When using SOAP noting, you need to be certain not to diagnose or extrapolate symptoms into medical or psychological judgments. IDEA’s Code of Ethics for Personal Fitness Trainers requires that trainers “practice within the scope of [their] education and knowledge” and “engage only in activities that fall within the boundaries of [their] professional credentials and competencies” (IDEA Health & Fitness Association 2001). And according to the ACSM Code of Ethics for Certified and Registered Professionals, “the personal trainer must keep detailed written records from the first client pre-screening to notes documenting each training session. These records are critical evidence that can document that the personal trainer exercised reasonable care in performing his or her professional duties” (American College of Sports Medicine 2007).
While Johnson realizes that SOAP noting will not protect his business from litigation, he believes “it will go a long way in providing evidence that my trainers’ workouts were safe, appropriate and within the scope of our field.”
Another area of potential liability is failure to protect client confidentiality. When you are documenting sessions, it is imperative that no harm come to a client’s reputation. Be sure to keep SOAP notes secure and accessible only to staff who work directly with the client.
SIDEBAR: SOAP Note Example
Here is an example of a SOAP note for a client who has type 2 diabetes.
- Client said, “I am happy now that I have gone down a pants size.”
- Feeling “deprived” on self-imposed diet.
- Inquired about blood cholesterol changes resulting from exercising.
- Client seems much more upbeat about exercise compared with earlier sessions, when she was pessimistic about the prospects of making progress.
- Waist circumference = 42 inches (has dropped 1 inch since 01/15/08).
- Weight = 190 lb (2 lb less than last week).
- RHR has decreased from 75 bpm to 70 bpm since 01/15/08.
- Client is losing weight at targeted rate per week (1–2 lb).
- Client’s physical therapist indicated progressing to lower-body closed-chain exercises.
- Client has difficulty balancing on left foot due to “minor numbness in big toe.”
- Refer client to a local registered dietitian for menu planning and healthy food alternatives.
- Schedule grocery store tour to help client assess nutritional content of various foods.
- Suggest client consult with her physician regarding changes in her lipid profile and “big toe numbness.”
- Explain effect of cardiovascular exercise on HDL levels.
- Increase target heart rate from 60% max to 65%.
The following links provide an in-depth view of how various allied healthcare professions have adapted the SOAP noting format.
- University of California School of Medicine, San Francisco, http://medschool.ucsf.edu/curriculum/clinical/guide/section3/notewriting.asp
of Counseling and Development (Summer
‑Jefferson Medical College Alpha Omega Alpha Guide to the Clinical Years, http://jeffline.jefferson.edu/JMCstudents/AOAclin/notes.html
SIDEBAR: SOAP Noting Dos and Don’ts
Follow these suggestions for creating effective SOAP notes.
Do use common industry acronyms (BP, HR, reps, etc.) when possible to reduce the length of the document.
Do identify daily strengths, weaknesses and symptoms pertinent to training goals and objectives.
Do note new medications and/or changes in current medications that may affect the exercise response.
Do suggest that the client follow up with his primary care provider regarding any medical concern that you observe or that the client describes during a training session. Avoid making referrals for specific medical conditions.
Do note dietary factors directly related to the training session, but avoid making specific nutritional prescriptions.
Do report the client’s emotional status based only on his self-report.
Do note factors outside the training session that the client self-reports and are pertinent to the client’s exercise/sport goals.
Do make your notations in a timely fashion so you don’t forget to include important information or data.
Don’t extrapolate symptoms into a diagnosis of any medical condition, syndrome or injury.
Don’t note over-the-counter medications that are not pertinent to the client’s workout or exercise response.
Don’t make a specific nutrition judgment based on the client’s self-reported eating habits. Keep recommendations general, and stay within your scope of practice.
Don’t attempt to diagnose psychological or eating disorders.
Don’t note factors of a personal or confidential nature.
Don’t be too wordy. Keep the notes brief and to the point.
Daniel Ball, MS, is an IDEA Master Personal Fitness Trainer and a senior trainer for ZenRock Fitness in Redmond, Washington. He can be reached at email@example.com.
Brian Murphy is a fitness specialist and personal trainer at the Lake Washington Technical College in Kirkland, Washington. He can be reached at firstname.lastname@example.org.
American College of Sports Medicine. 2007. American College of Sports Medicine code of ethics for ACSM certified and registered professionals. www.acsm.org/certification/generalinfor.htm; retrieved Jan. 31, 2007.
Durstine, L., & Moore, G. 2003. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics.
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