SOAP Note Assignment

Lou N. Luis

School of Occupational Therapy, Pacific Northwest University of Health Sciences

OTH 510: Introduction to Occupational Therapy

Dr. Brandon Imamshah

November 27, 2023

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 Evaluation

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 Client Information
Name: Bob N. Forapples Date of Service: 10/02/23
Diagnosis: right hemiparesis
Medical History:
● COPD
● left total knee replacement x 5 years ago
● macular degeneration.

Occupational Profile
Client name Bob N. Forapples is a 72-year-old male whose seeking services due to
experiencing a left CVA resulting in right hemiparesis. The client is a retired naval officer who
lives alone after his wife died one year ago. His daughter lives 30 minutes away and sees him
about once a week. Prior to CVA, reports being independent with all ADLs and IADLs,
including driving, grocery shopping, and attending medical appointments. His favorite
occupations include driving, drinking Brandy, watching TV, visiting with his daughter,
performing yard work and simple maintenance around the home, and cooking. Wants to get
back to driving, visiting with his daughter, performing yard work and simple maintenance
around the home, and cooking. A point of concern is his one-story home with 5-step entry/exit.

Subjective

Objective
Occupational Performance
● Mod physical A with UB and LB dressing and toileting.
● Min-mod physical A with bed mobility.
● Set-up and supervision with self-feeding

Performance Skills
● RUE shoulder AROM = 90 degrees elevation in the scapular plane.
● RUE shoulder PROM = 120 degrees in flexion with empty end feel (pain limited) and
hypertonic response (guarding) noted.
● RUE hand AROM = 50% digital flexion, no active extension
● RUE hand PROM = full motion noted in flexion and extension.

Client factors
● Manipulation = unable to oppose digits.
● Endurance = able to participate in five min of dressing tasks (seated and standing) prior
to resting; able to walk 10 feet from bed to bathroom prior to resting.
● Vision = 50% right visual field cut; reports blurriness and difficulty recognizing
shapes, faces, and color; unable to track objects in all visual quadrants.

Assessment
The client presents limited RUE function for both AROM and PROM presented in reduced
ability of endurance, vision capacity, and sensations presented in his performance in his
IADLs and ADLs. The client requires MIN-MOD A with all ADL performance due to a lack
of RUE shoulder mobility. endurance, vision, and proprioception limitations. The client's self-
awareness for rehab allows the potential for returning to ADLs to be positive but may be
impacted by a limited support system. The client would benefit from skilled OT services to
address limited vision capacity, RUE limitations, endurance, and manipulation.
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
Plan
It is recommended that the client participate in skilled OT services, 50-min/session, 5x/week
for 8 weeks in the SNF to work towards independence with ADLs and IADLs. The goal is to
focus on improving RUE mobility and strength, training, and increasing endurance. Adaptive
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 Daily Note

Client Information
Name: Bob N. Forapples Date of Service: 11/06/23
Diagnosis: right hemiparesis
Medical History:
COPD, left total knee replacement x 5 years ago, and macular degeneration.

Subjective
Bob reports deficiency with movement stating “can’t stop these jerks”. After the intervention,
the client stated “wasn’t that bad” after noticing improvement in their movement pattern. Bob
then reports with car washing activity stating that at the end range of reaching there is no
longer any pain.

Objective
During the initial intervention, the client was positioned on the right sideline with the
facilitation of vertical right elbow stability. Tactile assistance was used to aid in elbow flexion,
choppy movement initially but at the 5th rep movement was smoother. Past vertical full flexion
the clients lose control of function. Switched to elbow extension, continued using tactile
assistance, and saw activations of the triceps.
Next, the client was trained on hemi dressing technique, starting with physical assistance with
repositioning the t-shirt in a seated position. Client needed verbal assistance with the pullover
technique for sequencing w/ the t-shirt. Added a zipper front jacket for him to put on which
required physical assistance to put over the clients' shoulders.
During the last intervention of the day, the client worked on weight-bearing support using the
affected side while reaching to wipe down the car. Switched to weight bearing using his
unaffected hand while the effect hand did the reaching with physical assistance at waist level.
Client demonstrated ability with distance abduction reaching at shoulder height with only
needing standing contact guard assistance.
Assessment
Client has been making significant improvement in both RUE function for both AROM and
PROM movement and his RUE motor function, and sensations presented in his performance in
his IADLs and ADL. The client's response to therapy has been positive and has been making
progress in his goals keeping him on track. The client has been especially making progress in
elbow stability and reaching promoting his success in the intervention. Continued occupational
therapy is necessary to maintain the progression of his goals.

Plan
It is recommended that the client continues in skilled OT services for 50-min/session, 5x/week

for the remainder of 3 weeks in the SNF to work towards independence with ADLs and

IADLs. The goal is still to focus on improving RUE mobility and strength, training, and

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 increasing endurance.

Billing Information (add or delete rows as needed)

CPT Code Type of Intervention
97112 Client worked on his right UE neuromuscular reeducation of

flexion and extension.

97535 Trained the client on how to do hemi dressing technique for UB.
97530 Therapeutic activities of washing a car to improve reaching and

stability function.

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 Discharge Template

Client Information

Name: Bob N. Forapples Date of Service: 11/27/23

Diagnosis: right hemiparesis

Medical History:

COPD, left total knee replacement x 5 years ago, and macular degeneration.

Occupational Profile

The client's name Bob N. Forapples is a 72-year-old male who experienced a left CVA

resulting in right hemiparesis. At present, he has made significant improvements in his ability

to care for himself; and has enjoyed exploring new activities like board games, and social

activities like Bingo. Has established a small social group with individuals from the facility;

enjoys social interactions including playing board games and going on community outings;

likes eating in the dining hall as opposed to alone in his room.

Summary of Intervention Process

Start Date: 10/02/23 End Date: 11/27/23 Number of Sessions: 40

Targeted Outcomes: Occupational Performance Improvement to restore function in RUE,

and endurance. Quality of Life as it relates to participation in social events and maintenance of

house.

Approaches to Intervention:

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 Modify/adapt his approach to dressing techniques and his environment. Establish/restore RUE

function for both AROM and PROM movement and his endurance, vision capacity, and

sensations.

Types of Interventions:

Occupations of daily living were targeted like dressing. Training on hemi dressing techniques.

Activities that target manipulation, vision, and endurance.

Data Comparison (add rows as needed)

Measure Initial Discharge

ROM hand AROM 50% digital flexion, no active 90% full digital flexion
extension
25-50% active extension

hand PROM full motion noted in flexion full motion noted in flexion
and extension
and extension

shoulder 90 degrees elevation in 120 degrees elevation in

scapular plane scapular plane
AROM

shoulder 120 degrees in flexion with Flexion = 150 degrees

empty end feel (pain limited) with mild hypertrophic
PROM and hypertonic response response
(guarding) noted Abduction = 130 degrees
with mild hypertrophic
response
Vision 50% right visual field cut; 15% right visual field cut;

reports blurriness and mild blurriness; able to

difficulty recognizing shapes, recognize shapes, faces, and

faces, and color; unable to colors; tracks in all visual

track objects in all visual quadrants with mild

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 quadrants. overshooting

Sensation tactile, thermal, pain mildly impaired tactile,

sensibility, and thermal, pain sensibility, and

proprioception absent proprioception throughout

throughout RUE. RUE

Endurance able to participate in five min able to participate in 10 min

of dressing tasks (seated and of dressing tasks (seated and

standing) prior to resting; standing) prior to resting; able

able to walk 10 feet from bed to walk at slow pace x 10-15

to bathroom prior to resting. mins without rest

Manipulation unable to oppose digits 2 cm distance between

thumb and index finger
ADLs Feeding Set-up and supervision with Mod independence with
self-feeding (requires
self-feeding extra time and uses non-
dominant hand)
Bed mobility Min-mod physical A
Dressing/ Mod physical A with UB and Modified independence with
toileting LB UB dressing (uses hemi-
dressing technique, requires
extra time, and sits),
LB dressing (sits, requires
extra time), and
Toileting (uses grab bars for
sit to stand and to stabilize in
standing while pulling up
pants)
Progress Towards Goals

Goal Progress

LTG 1: Client will perform dressing and toileting at home w/ MET

assisted equipment and supervision as needed by 8 weeks.

LTG 2: Client will be able to get into a car with MID dependently MET
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
 by addressing endurance and RUE AROM and PROM by 8 weeks.

Summary:

The client made significant improvement in his ROM, vision, and endurance ADLs. The client

states that therapy was beneficial because they progressed in all areas. Client still requires the

use of assistive equipment to perform with MOD independence in ALDs which is exactly

where we wanted him. His endurance and ROM progress allow him to successfully get into

and out of the car with MID assistance.

Recommendations/Plan

It is recommended that the client be discharged from SNF OT services and referred to

outpatient OT services where the client can continue to work on working towards engaging in

physical activities at home, like gardening and yard work. An additional referral to a social

worker is made to provide additional resources on ways he can be independent in the

community. Client should maintain the use of assisted equipment as needed and continue with

home program that focuses on endurance and manipulation. A 50-minute follow-up

occupational therapy appointment is recommended in four weeks to monitor his progression

and compliance with the treatment plan.

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023