Evolution Note.

Subjective (S): depending on
What the
that the patient case.
reports, his Objective (O):
symptoms, Observations
description of clinics of
pain or doctor. By
discomfort example, studies
Characteristic and history. Plasnan(Pg u ): í
s Analysis (A):
nEexopsl , ica
uletr l a t s i
SOAP The opnoi d eos,
diagnosis palpatio i nes,
conclusive, etc.
possible will perform
diagnoses and (medication,
disposable, therapies,
surgeries,
etc).
In addition,
details the
goals; is
NOM-013-SSA2-
2015
• According to the standard, it is
established that the progress note
is a section that is found within
the clinical record.
Name of the Medical Unit (if
applicable)
N a om ay b ) r . e of the patient.
Age.
Items Sex (male or female).
File number.
Date.
I Vital signs.
Name and signature of the doctor.
As elaborated?
Document patient information such as: complaint,
symptoms, and medical history.
Take photos of the problems identified when performing
the clinical observation.
Perform an assessment based on the patient information
provided in the subjective and objective sections.
Create a treatment plan.
Complement the report with a digital signature.
Benefits
Allows effective communication : In when dealing with any patient visit us. You can use it to
In some cases, contact a allowing you to take control of everything better understand the patient's condition
patient for information the session and manage it well. if they have forgotten it.
can be heavy, especially if Allows easy and fluid documentation :
This is a poorly educated patient. But, In case you are not sure how
with a SOAP note, you will be guided on document your time with a patient,
how to communicate effectively with him a SOAP format can guide you on
patient with the sections of that How to structure your note.
you have. Serves as a reference point :
Increases courage and reinforces morale : doctors or nurses always
can help boost morale and You can consult the previous record
courage of medical professionals every time the same person comes back
Subjective: what the patient says
EVOLUTION NOTE
Center Name of patient Sex Sheet Proceedings
Example: the patient
Doctor says > my throat hurts. My body hurts and I have a
Number
M F
fever. This takesAge4 days. Height Weight Temperature F. Cardiac
• Objective:Subjective
what isDD/MM/YY
Date
seen | Hour : hrs. Bed number
Example: vital signs represent a temperature of 39º, BP of 130/80. The

patient has rashes, swollen lymph nodes, and a red throat with white
spots.
• Evaluation:
Aimwhat you think is happening
Examples Example: Assessment: This is a 23-year-old woman with a history of the

common cold and whooping cough who reports a sore throat, fever, and
of
fatigue. Clinical examination suggests bacterial pharyngitis due to swollen
Format lymph nodes and

•
the presence of white patches in the throat.
Analysis
Plan: treatment to be carried out.

Drafting
ummuemmmammmmmmmm Example: Acetaminophen- take every 6 hours x 5 days.
Penicillin (500mg) - once a day for 5 days.
Plan
There are no laboratories or consultations. Follow up for 5 days. If
symptoms persist or worsen. Drink plenty of water and consume vitamin
6.
Doctor's Name Doctor 's Signature

In
SUBJECTIVE
O (S)
• In physical therapy, this

section may include
information about the
duration, frequency, and
severity of pain or any other
musculoskeletal problems
the patient is experiencing.
OBJECTIVE (O) •mmmmum
• Objective findings obtained during the

physical evaluation of the patient are
collected, including tests of mobility,
strength, flexibility, balance, and any
other relevant tests. In physical therapy,
information about posture, joint range of
motion, muscle strength, and any other
tests that were performed during the
physical evaluation may be included.
Evaluation
(A)
• A diagnosis or conclusion is reached
about the patient's health status. In
physical therapy, this section may
include a diagnosis of the
musculoskeletal injury or condition,
an evaluation of the patient's
degree of disability or physical
limitation, and a determination of
whether physical therapy is
appropriate to treat their condition.
Plan (P)
•mmmmum
• Treatment plans and specific goals are

established to help the patient. In physical
therapy, this section may include information
about the exercises, manual therapies, or
assistive devices that will be used to treat the
patient's condition, as well as the number
and frequency of therapy sessions that will be
needed.
Example
S- Subjective : A 55-year-old
patient complains of low back pain for several months that extends to the right
leg. The pain worsens when sitting or standing for long periods of time. The
patient also reports muscle weakness and a tingling sensation in his right leg.
• O Objective: During the physical evaluation, a hunched posture and
limitation of the range of movements of the lumbar spine were
observed. Weakness was found in the muscles of the right lower
limb and a decrease in the right knee reflex. The patient showed
difficulty walking on tiptoes and heels.
• A- Evaluation: Based on subjective and objective findings. It was
concluded that the patient presents low back pain syndrome with
radiculopathy in the right leg due to the lumbar disc herniation.
• P- Plan: The following objectives and treatment plan were established for the patient:
1. Reduce pain and inflammation: treatment with analgesics and hot/cold therapy was
prescribed.
2. Improve strength and flexibility: a specific exercise program was designed to improve
muscle strength and flexibility of the spine and the muscles of the right lower limb.
3. Postural correction: the patient was taught postural correction exercises and the use of
a lumbar support device was recommended.
4. Education and Prevention: the patient was provided with information on the
prevention of low back pain and was recommended to avoid activities that could
aggravate their condition.
STATE SOCIAL ENTERPRISE EVOLUTION SHEET
-08
FRAYLUIS'PE LEÓN
FRAY LUIS DE LEÓN HOSPITAL
NIT. 819.001483-1
PHYSIOTHERAPY
RESPIRATORY THERAPY
Plate - Cupcake
# Clinic history
Surname Secondlastname
Age
Yo H|M
FORMAT
Years Months Days Service Living room or room Not bed
ORDERING
1-Information given by the patient 2 - Vital signs 3 - Most important findings
4.- Complications 5.- Presumptive diagnosis 6 * Definitive diagnosis
7.- Treatment 8 - Treatment results 9 - Change in pete management
10 - Observations 11 - Sign and code of the official
DATE
Bibliography
• Ramirez RA. Introduction to the topic of documentation of the medical act. Rev CONAMED. 2007; 12 (1): 29-30.
• Paneiva, B. (s/f). SOAP Note in Physiotherapy: Explanation, Guide and Examples - Guides . Lumiformapp.com;
Lumiform.
Retrieved on June 27, 2023, from https://lumiformapp.com/es/guides/que-es-una-nota-soap
• Mx, L. (2021, June 27). Evolution Note » 【 Examples, Templates 】 Word, Excel, Canva . Milformatos.com;
LaComuna.mx. https://milformatos.com/escolares/nota-de-evolucion/
•
Paneiva, B. (s/f). SOAP Note in Physiotherapy: Explanation, Guide and Examples - Guides . Lumiformapp.com;
Lumiform. Retrieved on July 1, 2023, from https://lumiformapp.com/es/guides/que-es-una-nota-soap

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Subjective (S): depending on

Example: vital signs represent a temperature of 39º, BP of 130/80. The

Examples Example: Assessment: This is a 23-year-old woman with a history of the

Format lymph nodes and

Plan: treatment to be carried out.

Doctor's Name Doctor 's Signature

• In physical therapy, this

• Objective findings obtained during the

• Treatment plans and specific goals are

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