Question

What is a good assessment and plan for a SOAP note for a pt with all normal findings for the musculoskeletal exam?

Answer 1

Assessment plan::

1)assess the every joint and inspect for swelling,redness ,warmth

2)check for any deformity

3)compare bones and joints in both sides to while checking deformity .

4)should know about the normal function of joints

5)you should palpate  every joint to find out any tenderness present

6)active and passive range of motion exercise should be done to know the movements

These are the normal assessment plan for a patient with normal findings.it is vital to assess the pain in joints during examination.if patient feel any discomfort you should stop to do this assessment for a while.