In the realm of podiatry, accurate clinical documentation is essential for effective patient care, particularly when assessing orthotic needs. This guide will walk you through the correct way to write and format clinical documentation using the SOAP (Subjective, Objective, Assessment, Plan) template, tailored for orthotics assessments.

Understanding the SOAP Template for Orthotics Assessment

The SOAP note format is a widely accepted method for documenting clinical encounters, providing a structured approach to capture patient information. Here's a detailed breakdown of each section with an example:

Subjective (S)

The Subjective section focuses on the patient's personal experience and complaints. For an orthotics assessment, it involves capturing detailed information about the patient's symptoms and history.

Example: A 45-year-old patient reports to the clinic for persistent right foot pain and swelling, particularly around the arch and heel area. The nature of the pain is described as sharp and throbbing, with a current intensity of 6/10, increasing to 8/10 after prolonged standing. The pain is localized to the right arch and heel and has been ongoing for 3 months with a gradual onset. Aggravating factors include standing for long periods and walking on hard surfaces, while alleviating factors are rest and ice application. The patient has tried over-the-counter pain medication, and the first steps in the morning are particularly painful, although the pain does not radiate to the toes, ankle, or leg.

Objective (O)

In the Objective section, the clinician records observable and measurable findings from the physical examination.

Example: Dermatological findings reveal right foot hyperkeratosis at the 1st PMPJ. Musculoskeletal examination shows a low arch in the right foot and functional ankle equinus in the right calf muscle. The right subtalar joint (STJ) presents a limited range of motion when weight-bearing, and the right 1st metatarsal joint (MPT) shows hallux limitus. A leg length discrepancy is noted, with the right leg shorter than the left.

Assessment (A)

The Assessment section encompasses the clinician's diagnosis or differential diagnoses based on the subjective and objective findings.

Example: The primary diagnosis is pes planus, with a differential diagnosis of plantar fasciitis.

Plan (P)

In the Plan section, the clinician outlines the recommended treatment and follow-up actions.

Example: The patient is advised to wear supportive shoes with arch support. A biomechanics and gait analysis was conducted, revealing overpronation, and custom orthotics are recommended. The importance of proper footwear and stretching exercises is discussed with the patient. A follow-up visit is scheduled in 4 weeks.

Enhancing Orthotics Documentation with Notis AI Medical Scribe

AI medical scribes like Notis are revolutionizing the way podiatrists manage clinical documentation. By automating the transcription of patient interactions into structured SOAP notes, Notis significantly reduces the time spent on documentation.

Notis offers key features that enhance efficiency and accuracy in podiatry practices. It integrates seamlessly with WhatsApp, making it easy to use without the need for additional software. The voice-to-text technology boasts a high accuracy rate, ensuring precise capture of clinical details. This allows podiatrists to focus more on patient care rather than administrative tasks, potentially saving up to 2 hours a day.

Moreover, Notis supports multilingual transcription, which is particularly beneficial in diverse patient populations. By leveraging AI, podiatrists can improve the quality and speed of their documentation, ultimately enhancing patient care and clinic efficiency in the specialty of podiatry.