Jordan University of Science and Technology OT 210-OT Fundamentals Lab Lab 10 SOAP Notes PDF

Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Lab 10...

Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Lab 10 SOAP Notes lab Soap notes components: Problem S = subjective O = objective A = Assessment P = Plan Problem: Medical diagnosis (e.g. adhesive capsulitis) or problem (e.g. frozen shoulder) Problem includes (as applicable): – Recent or past surgeries – Past conditions or diseases – Present conditions or diseases – Medical test results – Referral mechanism Subjective: Things the patient (or significant other) tells us about his/her: the patient’s voice! – Condition/chief complaint – Functional status/activity level – Cultural and religious beliefs – Employment status – Living environment – General health status – Social/health habits – Family health history Considerations: Use of the term “patient” Organization; concise Verbs: states, describes, denies, indicates, c/o Quoting the patient verbatim – To illustrate confusion or memory loss – To illustrate denial – To describe pain Objective: Things we find during the examination: – Systems review – Tests and measures – Functional skills – Medical history when taken from the medical record  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Organize and categorize – Use headings, caps & underlining – Use tables or charts – Use flow sheets Be specific – State the affected anatomy – State information in measurable terms – State type (e.g. transfer to where from where?) Assessment: Your professional opinion PT Diagnosis – Specific practice pattern or patterns (primary and secondary) – Inconsistencies – Further testing needed – Consultations and/or referrals w/ other practitioner(s) needed Prognosis: predict the level of improvement in function and the amount of time needed to reach that level. Consider: – Living environment – Patient’s condition prior to onset – Concurrent illnesses or medical conditions (co-morbidities) Plan: Where do you want to go and how are you going to get there? Goals: – Long-term – Short-term Intervention Discharge plans  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Abbreviations: The following are many (but not all) of the common abbreviations can be used in the SOAP notes ADHD Attention Deficit Hyperactivity Disorder AFO Ankle, Foot Orthoses A/K Above Knee AKA Above Knee Amputation AROM Active Range of Movement B/K Below Knee BKA Below Knee Amputation BP Blood Pressure BPL Brachial Plexus Lesion Ca Cancer CDH Congenital Dislocation of the Hip CNS Central Nervous System c/o Complaining of COPD Chronic Obstructive Pulmonary Disease CRF Chronic Renal Failure CTR Carpal Tunnel Release CTS Carpal Tunnel Syndrome CVA Cerebrovascular Accident CVS Cardiovascular System DD Developmental Delay DIP Distal Interphalangeal DOB Date of Birth DOI Date of Injury  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab DVT Deep Vein Thrombosis F Female FWB Fully Weight Bearing GBS Guillian-Barre Syndrome GCS Glasgow Coma Scale h/o History of HI Head Injury HOF Head of Femur ICU Intensive care Unit IHD Ischaemic Heart Disease IP Interphalangeal LBP Lower Back Pain L/L Lower Limb MCP Metacarpal Phalangeal MD Muscular Dystrophy MI Myocardial Infarction MS Multiple Sclerosis N/A Not Applicable NH Nursing Home NOF Neck of Femur NOH Neck of Humerus NWB Non Weight Bearing M Male OA Osteoarthritis PIP Proximal Interphalangeal  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab PROM Passive Range of Movement PVD Peripheral Vascular Disease PWB Partial Weight Bearing RA Rheumatoid Arthritis ROM Range of Movement RTA Road Traffic Accident SALT Speech and Language Therapy SCC Spinal Cord Compression T/C Telephone call THR Total Hip Replacement TIA Transient Ischaemic Attack TKR Total Knee Replacement TLSO Thoracic Lumbar Sacral Orthosis U/L Upper Limb WB Weight Bearing Δ Diagnosis # Fracture 1° Primary 2º Secondary  decrease  Increase  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Practice Review this sample SOAP and discuss with your colleagues the information in each section. Patient name: Rami XXX XXXX Age: 55 Gender: Male Occupation: car salesman date of evaluation: 11/3/2012 date of admission: 4/3/2012 Time: 1:25 AM Diagnosis: hip OA bilateral S: Rami is 55 yr M, he was admitted to K.A.U.H at 4/3/2012 and he has total left hip replacement in 7/3/2012. In addition, He has old surgery total right hip replacement before 2 years in 2010 at K.A.U.H too. He doesn't have any systemic disease only OA but he is smoker. He stays 1 week in hospital and discharged on 13\3\2012. Also, He has 3 sessions with PT and OT and he wants to continue PT in his home. He said he has experience with old surgery in the right hip and he want to back to his home because he feels boring in the hospital. However, He has a lot of pain especially on the operation place. O: The patient was lying supine on the bed and he is aware of his condition. The patient has tingling feeling on the right lower limb. The patient dominant hand is right. ADL by using Barthel index and the total score 70/100. Pain: 1/10. The patient is using a walker and walks independently. The patient lives in an apartment at the second floor and the building doesn't have an elevator. Motion/ Joint (side) AROM PROM MMT (left) Hip flexion 7 60 2- Knee flexion 65 65 3- Ankle planer flexion 35 50 3- Ankle dorsi flexion 15 15 4 (Right) Hip flexion 70 110 3- Knee flexion 110 130 3- Ankle planter flexion 45 50 4 Ankle Dorsi flexion 15 15 4 A: He needs maximum assistance from 2 persons standing beside him in walking because limitation of left hip flexion 53 degree, right hip flexion 40 degree and muscle weakness in right knee flexion 4, hip flexion 4, and left knee flexion 4. He is independent with moderate assistance from one  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab person in bed mobility from supine to side line due to pain and muscle weakness. He is independent with maximum assistance from two persons in ascending the stair because of limitation of ROM and muscle weakness. He is independent with minimal assistance by supervision in dressing the lower limb because of limitation of ROM and muscle weakness. P: LTG 1: Rami will be able to climb up and down his apartment stair independently with assistance (crutches) within 2 weeks. STG: 1. Rami will be able to climb up and down his building stair 1 time with maximum assistance (two persons) within 1st session. 2. Rami will be able to climb up and down his building stair 3 times with minimal assistance (one person) within 5th session. LTG2: Rami will be able to walk to the nearest supermarket (Distance 100 meter) and back independently within 2 weeks STG: 1. Rami will be able to go to nearest supermarket and back with maximum assistance (2 persons) within 1st session. 2. Rami will be able to go to nearest supermarket and back with minimal assistance (by crutches and supervision) within 5th session. LTG3: Rami will be able to drive a car independently within 2 month. STG: 1. Rami will be able to drive automatic gear car with supervision cues within 4th weeks. 2. Rami will be able to drive manual gear car with supervision cues within 6th weeks. The therapist will implement a 2 months treatment program, 2 sessions a week. The therapist will use the biomechanical approach to improve gate weight NWB to PWB and increase strength and endurance during walking. In addition, the therapist will educate the patient about protecting his replaced hip and using proper body mechanics. The therapist will use adaptation technique such as leg lifter to help the client in bed mobility that raises his foot from floor.  Jordan University of Science and Technology Faculty of Applied Medical Sciences Department of Rehabilitation Sciences OT 210 – OT Fundamentals Lab Second Assignment: 5% of the course grade Write a SOAP for the following case and hand it your lab instructor by 5/1/2025 Mr. J., 60 years old, had an ischemic right cerebral vascular accident with resultant left hemiparesis 12 years ago. He also was diagnosed with a slight carpal tunnel syndrome in his left hand two years ago. At this time, he had no pain related to that diagnosis. He fractured his left little finger four years ago but it has fully recovered. J was characterized as an individual with severe chronic stroke accompanied with significant learned non-use (heavily dependent on the non- affected upper extremity). Mr. J said that he values his family and really wants to resume his roles in taking care of his children and wife. Mr. J said he wants to return to his hobby of hunting. He said he is retired and doesn't want to work again. Using the COPM the therapist found that the most important and difficult functional activities for MR. J are: Washing his right side of the body with his left hand during bathing, cutting vegetables during cocking, putting a shirt on (buttoning), doing light home maintenance (driving screws for example), and playing cards. The occupational therapist evaluated Mr. J on 7/10/2011. And did the following tests indicated in the table: Test Scores Left UE MALᵅ Amount of use scale: 0.26/5 How well scale: 0.21/5 COPM Performance: 3.6/10 Satisfaction: 3.2/10 Left h Grip Strength 30.67 lb Left UE Joints strength (manual Shoulder flexion: 3-, Shoulder abduction: 3-, Elbow muscle test grades) extension: 3-, and Wrist extension: 3-. Left UE AROM Shoulder flexion: 0-115°, Shoulder abduction 0-100°, Elbow extension: 90-80°, and Wrist extension: 0-45°. Left UE PROM Shoulder flexion: 0-130°, Shoulder abduction: 0-105°, Elbow extension: 90-0°, and Wrist extension 0-50° Left UE tone (Ashworth scale) Shoulder flexion: 1+, Shoulder abduction: 2, Elbow extension: 2, and Wrist extension: 3