SOAP It UP
This part of a SOAP note documents what the team member reports about their injury, symptoms, or concerns.
What is Subjective?
Participation in the in-house treatment program is always this.
What is voluntary?
This is used to notify the appropriate team when additional review, support, or action is needed for a work-related injury or claim.
What is a referral?
These three letters are used when an employee misses scheduled work because of a work-related injury.
What is LTD (Lost Time Determination)?
This is the ongoing follow-up of an open work-related injury claim from initial treatment through return to full duty.
What is case monitoring?
Vital signs, swelling, bruising, range of motion, and other findings observed by the advocate belong in this section.
What is Objective?
When a team member attends an IHTP follow-up for a work-related injury, this system should reflect the visit/update.
What is Origami Risk?
Timely referrals help ensure injured team members receive these throughout their recovery.
What are appropriate support and resources?
These three letters track days an employee works under medical restrictions or modified duty.
What is ADD (Alternate Duty Days)?
During case monitoring, advocates track these three major areas throughout recovery.
What are work status, restrictions, and treatment progress?
This section documents the advocate's clinical impression based on the subjective and objective findings.
What is Assessment?
During each IHTP follow-up, the advocate reassesses and documents these to determine whether the team member is progressing as expected.
What are the team member’s symptoms and objective findings?
When a work-related injury is NOT appropriate for MCP self-care, the advocate should follow these recommendations and attach the IHTP report when applicable.
What are the MCP recommendations?
After every medical visit, the advocate should review this to determine whether LDD or ADD needs to be updated.
What is the team member's work status report?
During follow-up of an open work-related injury, this should be documented after each meaningful contact or case update.
What is a Case Monitoring note?
Treatment provided, follow-up instructions, restrictions, and next steps belong in this section of the SOAP note.
What is Plan?
An injured team member returns for IHTP treatment but reports worsening symptoms inconsistent with expected progress. The advocate should do this rather than simply continuing the existing treatment plan.
What is reassess and escalate/refer as appropriate?
Before initiating a referral, an advocate should ensure the referral contains enough of this for the receiving team to understand why assistance is needed.
What is relevant and accurate information/documentation?
A team member works the entire scheduled shift but performs modified duties because of medical restrictions. This should be tracked.
What is ADD?
In case monitoring, “TM returned WSR” is an example of this type of contact documentation.
What is Employee Contact?
A TM reports rolling their ankle. Swelling is observed, the Lower Extremity Injury MCP is completed, cold therapy is provided, and self-care instructions are reviewed. Match each item to SOAP.
What is S–report, O–swelling, A–MCP findings, P–treatment/follow-up?
A TM elects to participate in IHTP. How often should they follow up, and what is the maximum program length?
What is every day they are onsite, for a maximum of 7 days?
A team member's recovery is not progressing as expected and additional review or action is needed. Rather than allowing the case to sit unchanged, the advocate should initiate this.
What is an appropriate referral?
A team member is scheduled Monday through Friday. Following a work-related injury, the treating healthcare provider takes the team member completely off work on Monday and Tuesday. The team member returns on Wednesday on restricted duty. How should Monday and Tuesday be classified?
What is LTD (Lost Time Determination)?
A team member returns from a medical visit with new restrictions and another appointment scheduled. The advocate must update work status/restrictions, document the next appointment, communicate appropriately, and update this system.
What is Origami Risk?