Central Connecticut State University

REHABILITATION DOCUMENTATION

 

 

Accessible to AT Members Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Athletes who have had an initial injury evaluation and have been placed on rehabilitation must have documentation of their program.  The completed initial injury evaluation must be attached to the rehabilitation chart.  The athlete's chart is to be kept in alphabetical order and filed in the appropriate team folder located in the desk drawer. Athletes should be instructed to obtain their chart upon arrival to the athletic training facility.  Athletic training students, in consultation with the supervising ATC, may progress the athlete's rehabilitation program accordingly, but must record the SOAP notes daily.

SOAP Note Guidelines

  1. SOAP notes must be entered daily.

  2. If an athlete does not report, date the SOAP note and write, “did not report for rehab”.

  3. If the athlete has a day off, date the SOAP note and write, “day off”.

  4. If the athlete is traveling with the team, date the SOAP note and write, “no rehab due to team travel”.

  5. If the athlete is on vacation, school holiday, or spring break, date the SOAP note and write, “no rehab due to      (specify)       holiday or break”.

  6. If athlete does not report for 10 days:

    • Advise the athlete that their file will be closed if they do not report for rehab – date and indicate in SOAP note that the athlete has been advised.

    • Close after 10th straight day of not reporting – date and close file as indicated below.

  7. How to close a SOAP note:

    • “File closed due to athlete's non compliance”

    • “File closed due to athlete refusing further treatments and/or rehabilitation”

    • If athlete is cleared and has returned to full activity write, “File closed, Athlete returned to full activity with no further signs or symptoms”

    • Sign your full name after closing file. If an athletic training student closes a file, then a co-signature must be obtained from an ATC.

Reminders:

  • Use pen – preferably black ink, blue ink is acceptable.

  • Do not leave any blank lines between dates.

  • If writing on a new sheet cross off extra space and write refer to new sheet.

  • Print or write eligibly your complete last name when entering a SOAP note. 


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Question/Comments: Kathy Pirog at pirog@ccsu.edu