SOAP Notes

Client expressed frustration during session, saying “It’s hard, I don't want to” and becoming visibly upset.

• Subjective

• Objective

• Assessment

• Plan

Client will receive skilled OT 1x/day for 3 weeks

• Subjective
• Objective
• Assessment
• Plan

Decreased dynamic standing balance poses safety concern during dressing.

• Subjective
• Objective
• Assessment
• Plan

Patient reports that she has had difficulty holding a cup without spilling for the last few months.

• Subjective
• Objective
• Assessment
• Plan

Client participated in 30 min OT session in hospital room for UE activities to increase AROM in R shoulder and increase activity tolerance.

• Subjective
• Objective
• Assessment
• Plan

Patient exhibited agitation and compulsivity behaviors throughout the session.

• Subjective
• Objective
• Assessment
• Plan

Client will complete 3-step morning routine with setup assistance within 2 weeks.

• Subjective
• Objective
• Assessment
• Plan

Client demonstrated with difficulty laundry and cooking tasks routine due to memory and sequencing deficits.

• Subjective
• Objective
• Assessment
• Plan

Recent progress and motivation are good indications of potential to be independent with management of prosthesis.

• Subjective
• Objective
• Assessment
• Plan

Client would benefit from further instruction in IADL tasks along with visual perceptual and problem-solving activities to increase safety.

• Subjective
• Objective
• Assessment
• Plan