Sections of a SOAP Note
No description yet. This curated deck is ready for daily study.
Card preview (24)
Pt reports chief complaint is pain and stiffness
Subjective
Pt lives with wife and 2 small children
Subjective
L knee AROM 10-120 degrees
Objective
Pt amb with FWW x 100’ with minA x 1
Objective
Pt transfers from sit <>stand without assistance today, demonstrating pt has met goal.
Assessment
Pt receives R forearm PROM for supination and pronation in sitting 2 x 10 ea
Objective
AROM (R) elbow: 0 - 125 degrees
Objective
Pt’s gait distance improved from 25’ yesterday to 120’ today
Assessment
Add quadriceps setting, terminal knee extensions, and straight leg raises during next session.
Plan
Strength (L) LE: Knee ext 4/5, knee flex 5/5, ankle DF 3/5, ankle PF 2-/5
Objective
Pt c/o pain in the R hip
Subjective
Pt is oriented x 3
Objective or Subjective
Transfers: (I) with sliding board
Objective
Wound now consists of 75% healthy granulation tissue as compared to 10% last month
Assessment
3 MHz US (50% duty cycle, intensity 1.0 W/cm2) to dorsal aspect of left foot with US gel
Objective
w/c mobility: PT propels w/c on an outside sidewalk and up and down ramps with VCs for trunk positioning while on ramps
Objective
Pt c/o finger swelling and pain 7/10 since last tx session.
Subjective
Reports being unable to perform any ROM ex. d/t pain.
Subjective
Pt. reports difficulty eating and shaving d/t swelling and stiffness in the digits.
Subjective
Pt. ambulates 10’ x 2 with minA x 1 using standard walker NWB (R) LE with VCs for walker placement 100% of the time
Objective
(R) LE Girth: knee joint line 34cm, 2” above 38 cm, 4” above 42 cm, 4” below 35.5 cm
Objective
Vital signs before tx: BP 125/85mmHg, RR 15 breaths/min, HR 77bpm
Objective
Pt ambulates (I) with axillary crutches WBAT x 100’
Objective
Pt. indicates d/c plans are to return home
Subjective