PHT 1001 Introduction to Physical Therapy 1. For each of the following phrases,
ID: 122210 • Letter: P
Question
PHT 1001 Introduction to Physical Therapy
1. For each of the following phrases, indicate in which section of the SOAP they would be located, by marking each with an S,O,A, or P:
__ Has demonstrated improvement in transfer ability, as amount of assistance needed has decreased.
__Ambulated 75’ x 2 using wheeled walker, required minimal assistance for advancing walker and verbal cueing for proper pattern.
__Patient reports pain in R knee @ 5/10 at rest, 8/10 with activity.
__Nursing reports patient performed independent transfer in bathroom last night.
__Has met weekly goal of independent bed mobility.
__Patient says pain relief lasted for 4 hours after application of electrical stimulation at last intervention session.
__Will ask wife to attend next intervention session to observe and assist with patient’s transfers.
__Patient able to go up/down 3 steps w/ use of cane and 1 rail; independent with procedure after initial instruction in correct technique.
__Performed AAROM x 10 to L knee flexion/extension; patient required total assistance for completing last 10 degrees of motion during final 3 repetitions of extension
__May not be ready for d/c to lesser level of care as goal of independent transfer has not been met.
__Will ask PT to assess need to joint mobilization techniques to L shoulder.
2. Based on the interventions and topics listed below, list at least two additional questions that the PTA needs to be thinking about to gather enough information to write a comprehensive daily note.
a. Pain:
b. Gait Training:
c. Ice Packs:
d. Transfers / bed mobility training:
e. Exercises:
f. Patient instructions:
3. Imagine that you have obtained “answers” to each of the questions you listed previously. Choose 2 of the above interventions and organize the answers into a Subjective (S) and Objective (O) section of a daily progress note:
(S)
(O)
(S)
(O)
4. From the listed S and O above, write how you could reflect upon in the assessment section to demonstrate whether or not the patient is making improvements in his mobility.
Explanation / Answer
1.
__ Has demonstrated improvement in transfer ability, as amount of assistance needed has decreased. - A
__Ambulated 75’ x 2 using wheeled walker, required minimal assistance for advancing walker and verbal cueing for proper pattern. - O
__Patient reports pain in R knee @ 5/10 at rest, 8/10 with activity.- S
__Nursing reports patient performed independent transfer in bathroom last night. - A
__Has met weekly goal of independent bed mobility. - A
__Patient says pain relief lasted for 4 hours after application of electrical stimulation at last intervention session.- S
__Will ask wife to attend next intervention session to observe and assist with patient’s transfers. - P
__Patient able to go up/down 3 steps w/ use of cane and 1 rail; independent with procedure after initial instruction in correct technique.- A
__Performed AAROM x 10 to L knee flexion/extension; patient required total assistance for completing last 10 degrees of motion during final 3 repetitions of extension - O
__May not be ready for d/c to lesser level of care as goal of independent transfer has not been met. P
__Will ask PT to assess need to joint mobilization techniques to L shoulder. - P
SOAP: 1. S- Subjective: What patent told about the condition.
2. O- Objective: Measurements and specific treatments provided.
3. A- Assessment- Current condition of patient, assessment and analysis.
4. P- Plan: Planning about the treatment to be given or next steps to be taken after assessment.
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