Taking SOAP Notes

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.

Date: 2/15/08

Subjective

• 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.

Objective

• 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.

Assessment

• 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.”

Plan

• 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%.

SIDEBAR: Resources

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
• Journal
  of Counseling and Development (Summer
  2002),
  http://education.ufl.edu/Counselor/PracticumInternship/Files/SOAPNotes.pdf
  ‑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.

Dos

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’ts

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 protected].

Brian Murphy is a fitness specialist and
personal trainer at the Lake Washington Technical College in Kirkland,
Washington. He can be reached at [email protected].

References

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.