In S.O.A.P. notes format, where would a patient's range of motion be documented?

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In the S.O.A.P. notes format, the patient's range of motion would be documented in the "O" section, which stands for "Objective." This part of the note is used to record measurable, observable, and quantifiable data that can be assessed by the healthcare provider.

Range of motion is a specific and measurable aspect of a physical examination that can be observed through tests and assessments, making it appropriate to document in the Objective section. This may include the degrees of movement achieved in various joints, identifying any restrictions or abnormalities.

The other sections of S.O.A.P. serve different purposes:

  • The "S" stands for "Subjective," which includes information reported by the patient, such as their symptoms and personal feelings about their condition.

  • The "A" stands for "Assessment," where the healthcare provider evaluates the findings and provides a clinical judgment regarding the patient's status.

  • The "P" stands for "Plan," which outlines the proposed treatment and any future steps to be taken.

Thus, documentation of range of motion fits best in the Objective section due to its focus on observable and measurable data.

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