SOAP 1You are an exercise physiologist. Janet (37 years old) has come to see you because her doctor has
advised that she has begun perimenopause and would benefit from seeing an exercise physiologist.
In the first part of the interview, Janet has told you she works full-time as a receptionist and that in
addition to parenting a teenager (Stephen), she is also caring for her elderly mother who is on her
own as Janet’s father passed away seven years ago. Janet said she generally feels stressed because
of everything on her plate and she hasn’t done much exercise for the past 10 years, although she did
used to enjoy running when she was younger. You completed your interview and performed
relevant anthropometric and exercise testing of Janet. She is 164 cm tall and has a mass of 77 kg.
Her resting heart rate was 73 bpm, blood pressure was 141/83 mmHg, and she had a fasting glucose
level 6.8 mmol/L.
Your task is write up concise SOAP notes documenting your management plan (2 page maximum). As
part of this, you need to select relevant exercise tests and come up with realistic results. You may
also select other medical tests (with realistic results) that might be relevant and inform your
assessment and plan. Briefly (one sentence) justify any exercise and medical tests you perform.
Additionally, you may also add additional subjective information that you hypothetically collected
(research and think about what someone in Janet’s position might experience). In the Assessment
section, you are to interpret the subjective and objective information (e.g. compare to classification
cut-points or population norms). Newell’s model of constraints can be useful for interpreting both
subjective and objective information. As part of the Plan, you need to provide a FITT-based exercise
prescription (with brief justification), as well as list some additional allied health professionals (with
brief justification) that may be relevant in providing a holistic management plan for Janet.
Subjective
What the client SAYS – their descriptions. When speaking with your client, you would
learn many things about them, some of which is relevant to how you treat / manage
them.
E.g. This might include chief complaint, goals, feelings (e.g., fears, motivation,
likes/dislikes), history (e.g., progress/setbacks), opportunities/limitations (e.g. access to
resources & equipment, other health conditions), perceived barriers to exercise, etc…
Objective
Not opinion – measured / observed. Objective information could include:
– Anthropometrics (e.g. height, weight)
– Vital signs (e.g. BP, HR)
– Tests (e.g. 2+) that would have been done by a specialist or GP that
would lead to this diagnosis condition – include justification* and
plausible results.
– Relevant exercise capacity tests (e.g. 3+) – include justification* and
plausible results. These should be non-redundant and relevant to
assessment and plan
You will need to add (invent) relevant subjective information – imagine you are
interviewing your client – what might they say, given their situation?
We are looking for you to research the client/condition and consider the relevant
questions (and realistic answers)
You will need to add (invent) relevant information. E.g. given the
client/condition, what medical tests (and realistic results) would be likely for
diagnosis? As an exercise physiologist, what exercise tests (and realistic results)
would inform your assessment and plan? Don’t forget brief justification for these.
Assessment / Analysis
Your assessment / analysis / interpretation of the objective and subjective information
Plan
What do you plan to do with / for client?
Use Newell’s model of constraints to interpret individual / task / environmental
constraints. What are some constraints you can see that will impact this client?
Considering you are the exercise physiologist, what additional allied health
professionals (e.g. 3+) will you be engaging with? Provide justification*
Only include RELEVANT information.
Use your own research and ESSA manual to explain / interpret the results of the
How you will progress the client in an exercise program – what is their exercise
objective section. How do results compare to relevant normative data (e.g., percentiles) prescription? (Consider their condition and the research / guidelines)
and/or established classification cut-points?
– Provide FITT exercise prescription, with justification*, examples,
progression, contraindications, etc.
*These are modified SOAP notes. For example, you would not normally provide explicit justification. However, we need you to think about WHY you doing things. As a professional, you need
to be able to justify your decisions and not waste resources (including time). Are you doing something because it is logical and evidence supports it, or are you doing it for non-justifiable
reasons? This is about critical thinking – you need to be able to apply this to yourself and others, or you risk being and ineffective practitioner and/or being sold snake oil by charlatans!
References: APA 7th referencing
Writing: Clear and concise: SOAP notes are brief – e.g. clear bullet points, not lengthy paragraphs. Use shorthand & common abbreviations, as long as message is still clear
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Formatting
Title Page
Citation
Outline
