Orthotics & Prosthetics SOAP Note

Date of Service: [Date]

Encounter Type: [Evaluation / Fitting / Delivery / Follow-up / Repair]

Location: [Clinic or facility name]

Treating Clinician: [Name, credentials]

Referring Clinician: [Name, credentials] (Only include if applicable)

Device Context: [Device type, side, stage of care, reason for visit]

S: Subjective

[Chief complaint in patient's words]

[Relevant history for this encounter type] (For evaluations: onset, prior treatments, prior device history, current functional limitations. For fittings/follow-ups: changes since last visit, current wear schedule, device tolerance, new complaints. Include pertinent medical history, social context, and environmental factors only if they directly affect device selection, fit, or safety.)

[Patient-stated functional goals]

O: Objective

(Include measured values when available. Omit subsections that are not applicable; if clinically relevant but not assessed, state "Not assessed—[reason]".)

• Skin/Soft Tissue: [Location-specific findings: integrity, pressure areas, residual limb condition]
• MSK/Neuro: [Pertinent ROM, strength, sensation, tone findings]
• Functional Mobility/Gait: [Transfers, balance, gait observations with vs without device, assistive device use]
• Device Findings: [Fit, alignment, suspension; adjustments performed with rationale and immediate effect]
• Outcome Measures: [Measure name, score, interpretation] (If deferred, state reason)

A: Assessment

[Clinical synthesis linking subjective and objective findings to O&P conclusions]

(Present numbered problem list in priority order: skin/safety first, then function, then comfort/fit.)

1. [Problem title]: [1–2 sentence assessment with supporting evidence and clinical reasoning]
2. [Problem title]: [1–2 sentence assessment with supporting evidence and clinical reasoning] (Add additional problems as applicable)

Medical Necessity Rationale: [Why the device and key features are reasonable and necessary, linked to specific impairments and activity limitations]

Functional Level Documentation: [Current functional ability and expected potential with supporting evidence: daily activities, terrain, cadence, transfers, safety, endurance; functional classification] (Include for prosthetics involving component selection)

Progress Toward Goals: [Objective comparison to baseline and progress toward previously stated goals] (Include for follow-up encounters only)

P: Plan

(Organize by problem number matching the Assessment.)

1. Problem 1: [Interventions performed today; device modifications, fabrication steps, or orders placed; monitoring parameters and follow-up interval]
2. Problem 2: [Interventions, modifications/orders, monitoring] (Add additional problems as applicable)

Patient Education: [Donning/doffing, wear schedule, skin inspection, maintenance, red flags for device discontinuation] (Note method and patient demonstration/teach-back)

Follow-up: [Timing and modality of next visit; contingency instructions for urgent contact]

Delivery Documentation: (Include only if dispensing today)

• Items Delivered: [Description, side, quantity]
• Fit Confirmation: [Objective confirmation of appropriate fit and alignment]
• Patient Demonstration: [Patient demonstrates safe donning/doffing and use]
• Instructions Provided: [Written and/or verbal]
• Patient Acknowledgment: [Acknowledgment of receipt and understanding]

Clinician Signature: [Signature]

Printed Name/Credentials: [Name, credentials]

Date Signed: [Date]