SOAP 2015

#1
S: Patient stated ouch that hurts and pointed to her hip when bending down to complete
treatment activity.
O: Patient required total assist to don/doff shoe and AFO. Patient sat on the therapy ball with
MOA from therapist to support balance. Patient completed bending and reaching activity on R
and L sides, 2 sets of 6 repetitions on each side. Therapist educated patient on foot placement to
reach for cones. Patient kicked large ball with affected side (R) with AFO 30x to student. Patient
hit balloon hit balloon to therapist 30 with unaffected (L) arm. Her R arm was tucked to her body
A: Patient requires total assist with donning/doffing AFO and shoe which indicated decreased
balance and overall strength in order to bend and reach. Patient is increasing core strength and
balance as evidenced by completing reaching activity on R and L sides. Patient is increasing hip
flexion by kicking ball 30x with her affected leg. Patient demonstrates high tone in her R arm as
evidenced by the patient unable to use it while completing balloon activity.
P: It is recommended that the patient continue with skilled occupational therapy services 3x a
week for 45 minutes to increase cores strength, balance, use of affected limbs, and coordination
#2
S: Patient reported that wrist felt hot during ultrasound treatment. Patient stated a 4.5/10 pain
level for the day
O: The therapist applied 10 minutes of heat to the L hand. Patient complete 15 minutes of
ultrasound treatment on dorsal and palmar sides of the L hand at a 3.3 hertz level. The therapist
focused on the median nerve as that is where the patient indicated her pain. Patient completed the
following PROM and AROM exercises on the L hand with the therapist: wrist and elbow
flexion/extension and finger flexion/extension. Patient completed a red resistance hand griper
activity, 2 sets of 10 of the L hand. Patient completed the following Theraputty exercises:
squeezing, rolling, and flexion/extension of the fingers.
A: Patient demonstrated an increase in ROM after heat was applied as evidence by a decrease in
distance between thumb and fingers. Patient demonstrated skin sensitivity as evidenced by facial
expressions when therapist was applying the ultrasound. Patient demonstrated pain when
completing ROM exercises as she stated there was pain and her facial expressions.
P: It is recommended that the patient continue with skilled occupational therapy services to
improve L UE ROM, finger flexion/extension and L hand strength to improve overall function in
ADLs 2x a week for 1 hour until ROM and strength increases and hand pain decreases.
#3

S: Patient stated he did not stretch last night was stiff in his LE today. He stated his ankles hurt
when ambulating with quad cane and AFO on L leg.
O: The patient ambulated approximately 300 feet with quad cane with CGA from therapist.
Patient completed LE dressing with fair coordination and received education what leg to start
with first when donning and doffing pants. Patient doffed shoes independently. Patient used
reacher to doff R sock and used a sock aide to don R sock. Patient required full assist to don L
shoe. Patient completed balance activity that required bending, reaching, and twisting while
standing with visual guidance and CGA from therapist. Patient completed 3 sets and required a
break midway through due to fatigue in LE.
A: Patient demonstrated fair balance due to a decrease in coordination of L UE and L LE when
completing balance activity. Patient demonstrated an increase in independence with LE dressing
as evidenced by a decrease in instructions from therapist and a decrease in time to complete
dressing, but still requires total assist with donning L shoe. Patient demonstrates fatigue as
evidence by self-report and shortened walking distance.
P: It is recommended that the patient continue with skilled occupational therapy services to
increase overall coordination, energy conservation, and balance to improve independence with
ADLs and functional mobility, 3x a week for 45 minutes.