Queensland Health
Guidelines for allied health assistants
documenting in health records
Allied Health Professions’ Office of Queensland
Revised December 2019
Guidelines for allied health assistants documenting in health records
Published by the State of Queensland (Queensland Health), December 2019
This document is licensed under a Creative Commons Attribution 3.0 Australia licence.
To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au
© State of Queensland (Queensland Health) 2019
You are free to copy, communicate and adapt the work, as long as you attribute the
State of Queensland (Queensland Health).
For more information contact:
Allied Health Professions’ Office of Queensland, Department of Health, GPO Box 48,
Brisbane QLD 4001, email Allied_Health_Advisory@health.qld.gov.au, phone (07) 332
89298.
An electronic version of this document is available at
www.health.qld.gov.au/ahwac/default.asp
Disclaimer:
The content presented in this publication is distributed by the Queensland Government as an information source only.
The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or
reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all
liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might
incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed
on such information.
Guidelines for allied health assistants documenting in health records—Allied Health Professions’
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Contents
Introduction ........................................................................................................... 1
Prerequisite information ........................................................................................ 1
Why document? .................................................................................................... 2
What information needs to be documented? ......................................................... 2
Principles of documentation .................................................................................. 3
Documentation standards...................................................................................... 4
Alternative documentation formats ....................................................................... 5
SOAP .................................................................................................................... 5
SBAR .................................................................................................................... 5
Electronic health records ................................................................................... 5
Misconduct ................................................................................................................ 6
Appendices………………………………………………………………………………………...7
Appendix 1a: Assessment of competency ............................................................ 7
Appendix 1b: Knowledge check ............................................................................ 8
Appendix 1c: Health record audit .......................................................................... 9
Appendix 2: Commonly used abbreviations .......................................................... 10
Appendix 3: Documentation template examples ................................................ 11
Appendix 4: Example scenarios ......................................................................... 13
Appendix 5: Practice scenarios .......................................................................... 18
Appendix 6: SOAP format ................................................................................... 22
Glossary .............................................................................................................. 24
Guidelines for allied health assistants documenting in health records—Allied Health Professions’
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Guidelines for allied health assistants documenting in health records—Allied Health Professions’
Office of Queensland
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Introduction
These guidelines have been developed to facilitate the training of allied health assistants (AHAs) in
documentation for Queensland Health purposes. It is recommended that you clarify and discuss the
content with your supervisor. On completion of this training, AHAs should:
understand the purpose of documentation
know what should be documented
know what to include in health record entries
be confident about when and how to document
apply appropriate documentation standards.
Your supervisor or manager will assess your competency in documentation once you have
completed both the theoretical and practical elements of the training outlined in Appendix 1a. Once
deemed competent, there is no further requirement for the supervising allied health professional to
countersign AHA entries.
Please note
: Depending on the clinical setting, health records may be synonymously referred to as
patient charts, client files, medical records, etc. To ensure consistency, the term health record will be
used throughout this document.
Prerequisite information
You will need to complete the following training modules within five days of commencement. They can be
accessed online at
https://www.health.qld.gov.au/ahwac/html/training-modules.
clinical documentation
clinical handover
informed consent.
Prior to commencing training on documenting in health records, it is essential that you have a clear
understanding of the concepts of privacy, confidentiality and consent as they relate to healthcare.
Patient/client information is confidential and the precautions below should be
followed to ensure that all documented information remains confidential:
do not allow anyone to touch or look at a health record unless they are a healthcare provider
involved in the care of that patient
keep all patient records in a safe and secure place
do not tell anyone about what is in a health record unless they are taking care of the person.
Please note
: The obligation to respect the confidentiality and privacy of patient/client information
continues after employees have left Queensland Health employment.
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Queensland Health is subject to the following privacy and confidentiality legislation, which set the
standards for how personal information is handled:
Information Privacy Act 2009
Information Privacy Regulation 2009
Hospital and Health Boards Act 2011(Part 7)
Hospital and Health Boards Regulation 2012.
Additional information on health records and privacy is available at:
https://www.health.qld.gov.au/system-governance/records-privacy/health-personal.
Queensland Health employees are also required to comply with the standards of confidentiality and
privacy as specified in the Code of Conduct for the Queensland Public Service available at:
https://www.forgov.qld.gov.au/about-code-conduct.
To learn more about consent, please refer to: Guide to informed decision-making in healthcare
available at: http://www.health.qld.gov.au/consent/.
Why document?
Documentation is essential to maintain safe, high quality care. It is used:
as a communication tool to facilitate the continuum of patient/client care
to allow evaluation of the care provided
for research or epidemiological needs
to meet statutory requirements
in case the information is required for medico-legal defense.
What information needs to be documented?
You need to document significant aspects of patient/client care including:
all direct contact with the patient/client, carers or other related individuals
other significant activity that relates to patient/client care (including indirect contact), for
example, missed or cancelled appointments, information provided/posted to the patient/client.
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Principles of documentation
The format of your entries will be guided by Hospital and Health Service (HHS) policy as well as
discipline and work unit-specific practices. Regardless of the format, the following principles of
documentation apply:
always document as soon as possible after the intervention (e.g. occasion of service, phone
call)
content should be concise, relevant, appropriate and accurate
do not diagnose
use only standard abbreviations and avoid non-standard terminology
– it is important that your documentation can be understood by anyone reading the health
record
– check with your supervisor regarding which abbreviations you can use
– if you don’t recognise abbreviations you see in other entries, ask your supervisor or another
allied health professional to explain these to you
– refer to Appendix 2 for some commonly used abbreviations
be objective and factual
– be specific and avoid general terms
objective information is what is directly seen, heard, felt, or smelled:
– seen—for example, recording observations regarding bleeding, deformities, drainage, colour of
urine, patient/ client posture and/or attitude
– heard—for example, the patient/client’s comments, moaning, breathing abnormalities, speech
sound errors
– smelled—for example, vomitus odour
– felt—for example, hot, cold, dry or moist skin, range of movement
subjective information is your own personal bias, judgement or speculation about the patient
—
subjective statements should be avoided, that is, do not record your own emotional
statements or moral judgements
—
if you think it is important to include a subjective statement made by the patient/client or
another person you can record this (e.g. ‘husband reports improved speech’).
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At a minimum, the following information must be included in an entry:
When
Date and time of patient/client
contact/activity
Who
Who was involved?
E.g. patient/client, carer, nurse reported stable
observations, discussed with physiotherapist
What
What did you observe and do?
Observations/ events relevant to
the session
Therapy/ treatment provided
How
How did you carry out the task?
E.g. with prompting and minimal assistance;
walk belt
Why
Why did you perform this task?
E.g. as per the treating therapist’s instructions;
as per surgical pathway
Documentation standards
Record in chronological order, that is, in order of date and time.
Check that you have the correct health record and ensure that the front and back of every
page has an identifying label/information attached.
Black pen only.
Ensure your writing is legible.
Avoid spare lines and gaps within and between entries.
Always time and date entries:
– try to write the entry as soon as possible after the intervention, if there is a long delay,
record when you saw the patient as part of your entry
– document the time that you write the entry
– use a 24-hour clock format— 9am as 0900, 1:30pm as 1330
– do not time or date entries retrospectively (that is, back-date).
Clearly label your entries:
– use a discipline sticker, for example, ‘Speech Pathology’
– indicate you are an AHA
– sign entries and clearly print name and designation (title)
– once you have been deemed competent by your supervisor, there is no requirement for
the allied health professional to countersign entries.
If errors are made:
– draw a neat single line through writing. Sign and date this change. If the whole entry is an
error, write ‘Written in error’ or ‘Written in wrong chart’
– do not use white out correction fluid (liquid paper)
– do not retrospectively amend.
Complete and then discuss the templates in Appendices 3–6 with your supervisor to determine if
this is how you should document at your facility.
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Alternative documentation formats
SOAP
A number of HHSs have adopted the SOAP system for clinical documentation as follows:
S = subjective information
O = observation/objective information
A = assessment
P = plan.
Commonly used expansions to SOAP include:
I = intervention, treatment or care provided
E = evaluation—the results/impacts of the treatment or care
R = recommendations/ revisions—what is recommended to happen next or what has changed
in the patient/client care.
1
For additional information on the application of SOAP and some examples, refer to Appendix 6.
SBAR
Other healthcare services have implemented the SBAR as a standardised communication protocol for
communicating clinical information:
S = situation
B = background
A = assessment
R = recommendation.
Electronic health records
Many HHSs in Queensland are now documenting using an integrated electronic medical record
(ieMR). The same principles and standards will apply but using a digital document rather than a
hand-written document.
Employees should continue to observe Queensland Health legislative and information confidentiality
and privacy policies when accessing, viewing, using and transmitting patient/client information
electronically.
1
WA Country Health Service [WACHS], Assistant training mini-module: Documentation,
Government of Western Australia,
Department of Health, 2009. Available at:
https://www.cta.qld.edu.au/files/documents/84/wachs_g_aha_trainingmini_module.pdf
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Misconduct
Misconduct associated with documentation includes:
breaches of privacy and/or confidentiality
failure to keep required records
inappropriate, intentional destruction of documentation
falsifying records, for example, documenting care that did not occur, signing a document that
is known to contain false or misleading information, and signing for care that was carried out
by another person and not documented as such.
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Appendix 1a: Assessment of competency
Your competency in documenting in health records will be assessed once you have completed both the theoretical and practical elements of
the training outlined below:
Name:
Learning objectives
Essential elements Date achieved
Read and understand theory
Prerequisite information Clinical handover
Documentation
Informed consent
Privacy and confidentiality
Guidelines for AHAs documenting in health records
Relevant HHS policy
Work unit-specific guidelines, procedures and instructions
Practice documentation
Example scenarios provided [Appendix 5]
Real work situations under supervision
[Minimum of three examples]
Assessment of competency
Satisfactory completion of Knowledge check [Appendix 1b]
Satisfactory completion of Health record audit [Appendix 1c]
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Appendix 1b: Knowledge check
1
Write your answers in the spaces below before discussing with your supervisor.
1. Why is documentation important?
2. When should you write patient/client notes?
3. How can you make sure your patient/client notes are kept confidential?
4. If you make a mistake when writing in patient/client notes, how do you correct this?
_
5. What types of things should be included in patient/client notes?
6. What type of abbreviations should be used in a health record?
7. How should you record information provided to you by someone else, rather than what you have
observed yourself?
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Appendix 1c: Health record audit
Name of candidate
Assessor name
Name of workplace/
organisation
Dates of assessment
Procedure/activity
Document client care in the health record
Did the candidate perform the following skills?
Comments
Yes
No
Demonstrated awareness of where to access health
record
Privacy and confidentiality maintained when using health
record
Black pen only
Legible writing
Dated
24-hour clock
Signed, printed name, designation and contact details
written
Written information clear, concise, objective statements
used where possible
Written information accurately reflects the patient/ client
presentation and intervention provided
Appropriate language used, abbreviations
Health record appropriately filed at completion
The performance was: Not competent
Competent
Feedback provided
(if not competent, detail skill development required before reassessment)
Assessor signature: Date:
Candidate’s signature: Date:
Appendix 2: Commonly used abbreviations
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Documentation format
Time descriptors
S/
Subjective information
mane
In the morning
O/
Objective information
am
Morning
I/
Intervention
pm
Afternoon
Rx
Treatment
1/7
One day
A/
Assessment
1/52
One week
P/
Plan
1/12
One month
c/o
Complains of
Therapy-specific
o/e
Objective Examination
Mob
Mobilise
//
Outcome of intervention
ROM
Range of motion
Mobility aids
HEP
Home exercise program
SPS
Single point stick
ex
Exercise
4PS
Four-point stick
ADL
Activities of daily living
4WW
Four wheeled walker or ‘wheelie walker’
Activities of daily
living (ADL) aids
FASF /
ESF
Forearm support frame or Elbow
support frame
OTF
Over toilet frame
W/C
Wheelchair
HHH
Hand held hose
Indep
Independent
Other
SPS
Single point stick
Pt
Patient
4PS
Four-point stick
WNL
Within normal limits
Assistance required
NAD
Nil abnormality detected
s/v
Supervision
Physical status
Min
Minimal
BMI
Body mass index
Mod
Moderate
Wt
Weight
Max
Maximal
1xA
One person assist
2xA
Two person assist
Appendix 3: Documentation template examples
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This section includes examples of treatment for dietetics, speech pathology (SP), occupational
therapy (OT) and physiotherapy (PT). Whilst these examples do not form a comprehensive list, it
will give you an idea of format and content.
Example 1: Acute ward AHA
DATE
TIME
[DISCIPLINE] ALLIED HEALTH ASSISTANT
Patient consent obtained. Nurse reports stable vital signs.
[Document relevant comments from patient]
Treatment – Mobilised X with X aid and X assistance as per PT instructions.
–
Completed X exercises as per PT instructions.
–
Pt and carer provided with and discussed equipment hire handouts for X aid as
per
OT instructions.
–
Dressing retraining using X aid with X assistance as per OT instructions.
–
Performed dysarthria drills as per SP instructions.
–
Pt and carer provided with information and training in the use of home feeding
pump as per dietitian instructions.
[Comment on relevant observations}
Plan: Feedback to PT/OT/SP, review X
[Signature] (Printed Name)
Allied health assistant
Example 2: Community AHA home visit
DATE
TIME
[SERVICE NAME] ALLIED HEALTH ASSISTANT
Home visit conducted on / / at X time. Allied health assistant, client and client’s
spouse present.
Home program completed and X strategies implemented as per OT/PT/SP
instructions.
Plan: Appointment scheduled with AHA __/__/ for next home visit. Provide
feedback to OT/PT/SP.
[Signature] (Printed Name)
Allied health assistant
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Example 3: Negative response to intervention
DATE
TIME
[DISCIPLINE] ALLIED HEALTH ASSISTANT
Patient consent obtained. Nurse reports stable vital signs.
[Document relevant comments from patient] Treatment—
carried out exercise program as per PT/OT/SP.
Pt completed X mins/reps/m, reported/pt became (e.g. chest pain, dizziness,
pale). Exercise ceased, pt returned to chair/bed and nurse notified immediately.
Feedback provided to PT/OT/SP.
Plan: Await further instruction of PT/OT/SP
[Signature] (Printed Name)
Allied health assistant
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Appendix 4: Example scenarios
Read all examples as they represent different interactions with patient/clients which may be helpful
in guiding your documentation.
Scenario 1: PT assistant, medical ward
You are asked to see Mrs. Smith, an 85-year-old female patient who is in hospital following a fall five
days ago—with no significant injuries. You are informed by the PT that Mrs. Smith mobilises about
50m with a wheelie walker (4ww) and standby supervision. You are asked to do sit to stand
exercises, as tolerated from the patient chair, and take Mrs. Smith for a walk.
You speak to the nurse who reports Mrs. Smith has a sore back but has had pain relief and her
vital signs are stable and the nurse is happy for you to carry out the exercise program. When you
ask, Mrs. Smith tells you that her back is still sore (no worse/better) and didn’t sleep well, but she
does agree to go for a short walk. After the walk, Mrs. Smith agrees to a few sit to stand exercises,
but after completing five exercises she reports being fatigued. After a rest, Mrs. Smith completes a
further three sit to stand exercises. Mrs. Smith required prompting and minimal assistance to carry
ou
t the sit to stands.
Example documentation OO3 level
7/10/09
1430
Physiotherapy assistant
Patient (pt) agreed to participate. Nurse reports stable vital signs; pt has had analgesia
for sore back.
Treatment as directed by PT: Mobilised 50m with 4ww and supervision and did sit to
stand exercises x8reps with one rest due to reported fatigue.
Plan: Feedback to PT, review 1/7.
[Signature] (Printed name)
Allied health assistant
Scenario 2: PT assistant, rehabilitation unit
You go to see Ben, a 21-year-old who sustained a traumatic brain injury two weeks ago. You have
been asked to take Ben for a walk outdoors (with supervision), up and down the stairs holding one
railing, heel-toe walking and practice standing on one leg. Yesterday Ben was able to do these
activities and he stood on his right leg for four seconds and left leg for two seconds.
When you see Ben, he complains of a headache, but he is keen to do his program. The nurse
reports Ben is okay to participate in his rehab program.
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You walk Ben to the gym. You practice walking sideways and backwards and then attempt heel-toe
walking. You notice that Ben is not performing his walking activities as well as usual. When you
start single leg stance (SLS) practice, Ben appears unable to stand for more than one second on
either leg, despite encouragement and, what appears to be, sincere attempts. You notice Ben
seems frustrated and when you ask, he reports his headache is worsening. You walk Ben back to
the ward and immedi
ately inform the nurse of his worsening headache and poorer balance.
Example documentation OO3 level
8/10/09
0955
Physiotherapy assistant
Pt reported headache, consented to treatment
Treatment as per PT instructions. Walk sideways, backwards, heel-toe, SLS.
//Treatment ceased as pt reported headache worse. Returned to ward. Nurse and
PT informed.
Plan: Await further instruction from PT.
[Signature] (Printed name)
Allied health assistant
Scenario 3: OT assistant, Geriatric rehabilitation unit
You are asked to see Mavis, an 87-year-old lady, with some memory problems, who sustained a
fractured neck of femur and has had a partial hip replacement. Your task is to undertake daily
dressing retraining, as per ADL retraining guidelines, with Mavis, ensuring that she adheres to hip
precautions.
The OT has done an ADL assessment and recommends that Mavis use a shower stool and
dressing stick. In this assessment Mavis required moderate to maximal prompting to ensure she
adhered to hip precautions and used the equipment appropriately.
On your third therapy session Mavis was ready with her toiletries, clothes and dressing stick. You
observe that she is now able to use the dressing stick correctly but still requires minimal to
moderate prompting to stop her bending too much at the hip. Mavis appears to remember all other
hip precautions as she avoids these movements during the task.
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Example documentation
1/10/09
0830
Occupational therapy assistant—ongoing review
Pt agreed to shower this am. Nurse reports no medical concerns.
Pt prepared with toiletries, clothes and dressing stick
Pt stated 2 of 3 hip precautions, but did not list the precaution not to over-bend at hip
- Same observed during retraining.
Treatment as per OT plan, dressing retraining using shower stool and dressing stick.
//correct use of dressing stick, prompt for hip precaution safety.
Plan: Feedback to OT re frequency/progression of further sessions.
[Signature] (Printed name)
Allied health assistant
Scenario 4: OT assistant, medical ward
You are asked to provide a handout on equipment hire information to a patient and their carer. The
OT has completed the patient assessment and this intervention is required for discharge. The
equipment to be hired includes an over-toilet frame and shower stool. You complete this task and
document in the chart.
Example documentation
5/10/09
1520
Occupational therapy assistant
As per OT: Pt and carer provided with and discussed equipment hire handouts for
over toilet frame and shower stool.
P/ Feedback to OT.
[Signature] (Printed name)
Allied health assistant
Scenario 5: SP assistant, medical ward
You are asked by the ward SP to perform daily indirect swallowing rehabilitation with Mr. Jay, a 48-
year-old male with dysphagia (swallowing difficulties) and aspiration pneumonia, following outpatient
radiotherapy to his oropharynx and neck.
The SP assessed the patient and developed and implemented a treatment plan. After receiving
training from the SP, you are asked to facilitate the patient to carry out a list of indirect swallowing
exercises twice a day.
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When you go to see the patient, the nurse reports no concerns and the patient reports he is keen to
do his exercises. During the session he complains that he is constipated and also notes that his
mouth is very dry. You follow the exercise guideline which states:
Twice daily exercise program for Mr. Jay
Prepare the environment:
ensure patient alert
position upright in chair/bed
minimise distraction and ensure privacy: pull curtains etc.
Exercises:
1. oromotor strengthening and ranging exercises, as per exercise sheet attached
2. head lift exercises, increase repetitions, as able
3. tongue-hold exercises (Masako manoeuvre), as per exercise sheet.
Considerations:
use water spray to lubricate mouth as required
use verbal cues and mirror to improve performance.
You complete the exercise program, noting that he:
appeared to have difficulty performing the tongue ranging exercise on the left side, but this
improved when you used the mirror and provided verbal guidance
did 20 head lift exercises in a row, compared to 15 yesterday
did 15 tongue exercises, but required the water spray every fifth dry swallow due to c/o mouth
dryness.
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Example documentation
20/10/09
1150
Speech pathology assistant—swallow rehabilitation session
Pt consented to session, complaining of ‘dry mouth’ and ‘constipation’. Nurse
reports nil concerns.
Pt positioned upright in chair, curtains pulled, minimised distractions.
Performed swallow Rehabilitation Tasks as per SP prescribed program.
Oromotor strengthening and ranging exercises, observed difficulty performing tongue
ranging task to the left side, improved with the use of a mirror and verbal feedback.
Head lift exercises performed by patient with verbal direction, increased amount of
head lifts tolerated today to 20 consecutive.
15 tongue hold exercises, performed with nil difficulties, required water spray to
lubricate mouth after every fifth dry swallow.
Plan:
AHA to feedback to SP regarding c/o dry mouth
AHA to liaise with nurses regarding pt c/o constipation
Ongoing daily swallow rehabilitation sessions with patient at bed-side as per SP.
[Signature] (Printed name)
Allied health assistant
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Appendix 5: Practice scenarios
Please complete the relevant entries for the following scenarios, then discuss with your supervisor:
Scenario 1: OT assistant, acute ward
You have been asked to undertake daily Post Traumatic Amnesia Assessment (PTA) on Cooper
who is a 23-year-old male. Cooper is now three days post motorbike accident where he lost
consciousness at the scene. His PTA score has been 10/12 for the last two days.
When you see Cooper, he is able to name the OT who had seen him, although he reports still being
unable to remember the accident. Cooper appears to be distracted when visitors entered the room
and requires re-direction to continue. His PTA score today was 11/12 (orientation was 7/7, recall
4/5).
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Scenario 2: OT assistant, rehabilitation unit
You are involved in running cooking groups with one of the OTs. Prior to the sessions you discuss
with the patients what they want to cook and ensure the necessary ingredients are available. You
help bring patients to the group and position them in the room to facilitate their independence.
The therapist asks you to help Bill and Hazel who both have poor endurance for everyday tasks and
need regular encouragement to continue with the task.
Over the course of the week, Bill participates in three cooking groups and was able to mobilise
around the kitchen independently and safely. He appeared progressively less fatigued over the
sessions and required less prompting.
You have been asked to do a weekly health record entry about Bill’s progress in the cooking
groups.
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Scenario 3: PT assistant, outpatients
In the outpatient department, you facilitate patients following ankle sprains to carry out the set of
exercises, as determined by the PT and using a written pathway.
Today, Jeremy (a 19-year-old male, four weeks post left ankle sprain) attends and you are to carry
out the following exercises, at level 4 on the pathway:
heel raises, 2 sets of 10
toe raises, 2 sets of 10, standing on the affected leg
single leg stance (SLS), 10 reps of as long as possible
calf stretches, 2 reps of 30 seconds
balance board for 2 minutes.
Your screening assessment of performance includes:
calf length— facing the wall with knee bent/touching the wall, measure distance of toe to wall
time of SLS.
The pathway states that when the patient can carry out 10 sec SLS on the affected side, they are
then to be referred to the PT to commence quarter squats in SLS. He completes all exercises and
manages 11 seconds SLS on the left side. The toe to wall distance is 3cm. You ask the PT to
review the patient to progress the exercise, as per the pathway. The PT checks Jeremy’s technique
in doing the new exercise and then leaves you to complete two sets of 10 quarter squats in SLS,
with the direction that if the Jeremy completes that with no concerns, then the new exercise is to
replace SLS in his home exercise program (HEP).
Jeremy reports discomfort at the front of the ankle during the calf stretches and balance board
activities, but he completes the new exercises with no concerns. His next appointment is in one
week and he is to continue his HEP 3 times daily.
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Scenario 4: Community Allied Health Assistant, community rehabilitation
Mrs. Singh is a 72-year-old female who had a mild stroke resulting in mildly slurred speech. She was
discharged from hospital earlier this week. She lives independently at home and appears highly
motivated to improve her clarity of speech. Her stated goal is to feel comfortable with her speech
when interacting socially with her friends.
After the SP reviews Mrs. Singh, she asks you to carry out speech drills focusing on multi-syllabic
words, as per the handouts the SP provides. Mrs. Singh reports compliance with her home exercise
program and her husband notes that her speech had already improved.
During the session you work with Mrs. Singh through two pages of speech drills focussing on
increasing complexity in multi-syllabic words. She participates well, however you note she has
difficulties when the words contain four syllables or more. Mrs. Singh reports being aware of this.
Mrs. Singh is booked in for her next review in three days and the SP has asked you to reinforce that
she do her home exercise program twice daily.
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Appendix 6: SOAP format
Component
Description
Examples
S
states the point of view of the
patient/client
includes symptomatic data
includes history, home situation,
emotions or attitudes, goals,
complaints, response to
treatment
note verbal consent.
c/o painful left knee
slept poorly
consent obtained
lives with husband in lowset home,
with 1 step to enter (no rail)
nurse reports obs stable
nurse happy for patient to
participate in exercises
O
physical findings (physical signs)
the results or outcomes of
treatment that can be clearly
measured and does not contain
value statements
list current problems in
chronological order not priority or
severity
each problem numbered for ease
of reference.
sitting in chair
alert and cooperative
walked 40m with 4ww and
supervision
speech appeared slurred
appears to be ignoring left side
A
patient/client’s reaction to
treatment
outcome of intervention
‘//’ may also be used to indicate
response to individual
treatment
activities.
participated in Rx
increased number of sit-stand from
5 yesterday to 2x5 today
reported fatigue after intervention
pt reports headache following Rx
P
plans for ongoing treatment
description of action and change
in treatment plan.
to complete ex. program 2 times
this pm
review in 2/7
refer to nurse regarding reported
headache
Guidelines for allied health assistants documenting in health records—Allied Health Professions’
Office of Queensland
- 23 -
Example Scenario 1: Documentation using SOAP format
7/10/09
1430
PT assistant
S/ c/o sore back ISQ, consent obtained.
Nurse reports stable vital signs. Has had medication for back pain.
O/ sit to stand with minimal assist and prompts
Mobile with 4ww and close supervision
Rx as directed by PT
Mob 50m as above
Sit to stand as above 5 reps, rest, 3 reps.
A/ c/o fatigue during treatment.
P/ Encouraged to mob twice this pm with nurse. d/w Nurse
Review 1/7, discuss with PT re ongoing back pain.
[Signature] (Printed name)
PT Assistant
Example Scenario 2: Documentation using SOAP format
8/10/09
0955
PT assistant
S/ c/o headache, stated keen to participate
Nurse agrees to pt participation in rehab program
O/ Mob indoors independent
SLS (R)< 1 sec, (L)< 1 sec
Rx as per PT instructions
Mob to gym
Sideways, backwards walking, each x6 lengths of bars Heel-
toe walking approx. 20m
SLS alternate legs// pt appeared frustrated and c/o worse headache, Rx ceased,
returned to ward with pt, nurse informed and nurse contacting Dr for review.
A/ Balance appears worse today, SLS reduced from 4sec to 1 sec on R leg. Pt
appeared frustrated with performance and c/o worsening headache.
P/ refer to PT to review pt
[Signature] (Printed name)
PT Assistant
Guidelines for allied health assistants documenting in health records—Allied Health Professions’
Office of Queensland
- 24 -
Glossary
Privacy The protection of personal information in accordance with
the Information Privacy Act (2009). Privacy applies only to
personal information.
Confidentiality A legislative or contractual mechanism designed to protect
information in a particular context. Confidentiality can apply
to both personal and non-personal information.
Consent The concept of consent as it relates to the handling of
personal information does not encompass a person’s
consent to treatment. Consent may be express or implied
and may relate to handling of patient or staff personal
information, or personal information of a member of the
community who has dealings with Queensland Health.
