For this final SOAP note assignment, you are to read the treatment session below

Question

For this final SOAP note assignment, you are to read the treatment session below and write a SOAP note. Use abbreviations and medical terminology in this SOAP note. If the symbols are hard to insert, it is ok to spell them out or abbreviate. Your finished product should look like an official SOAP. Please read the OT treatment session and write a SOAP note. An occupational therapy treatment session with Mrs. B. On May 5, 2009 you see Mrs. B. for treatment session in her room at the rehabilitation center. The first goal for this treatment session is to have Mrs. B complete all of her grooming (washing face, brushing hair, and teeth) at the sink safety, without physical assistance or verbal cues, from a standing position. Last week, she completed grooming with minimal physical assist and continual verbal cues for sequence. You set out all of her personal grooming items (toothbrush, toothpaste, soap, hairbrush etc.) and a washcloth and towel at the sink for her. The second goal for this treatment session is to increase her physical endurance for daily activities from 10 at the end of the last session to 20 minutes today. Prior to beginning, you verbally review the upcoming activities and the goals for the session with Mrs. B She transfers from the bed to her walker with verbal cues for sequence. She uses the walker with stand by assist. Once at the sink, she stands for about one minute and finally asks, "What am I supposed to do?" With your verbal cues, she is able to complete washing her face and brushing her teeth in 10 minutes. You notice her respiration rate increasing, and her standing balance appears less stable. You walk beside her to the bed and help her return to bed to rest.

Explanation / Answer

5th May 2009,

Occupational therapy treatment, Mrs. B

S: Patient in rehab center. Previously Pateint completed grroming with minimal physical assistance but with constant verbal cues. Level of physical activity- 10 mins

O: Pateint was reviewed about the treatment plan. As conveyed pateint shifted from her bed to the walker. Walked till the sink but had loss of memory. With assistance of verbal cues pateint completed her grooming. Respiration rate increased. Weak legs anxiety or shaky legs.

A: Pateint is recovering but slow.

P: Have to repeat the grooming plan next week. Increase the physical activity to 20 mins. Follow up with cardiology for high respiration rate. Check up for weak legs anxiety.

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