For this SOAP note critique assignment, you are to read and rewrite the SOAP not
ID: 166778 • Letter: F
Question
For this SOAP note critique assignment, you are to read and rewrite the SOAP note, making corrections and changes and following SOAP note documentation rules. This SOAP note has some errors, is missing major elements, has some elements in the wrong place and has sentences that need to be rephrased using appropriate medical terminology. The 'A' part of the note should highlight a reason for some of the elements of the 'O' - what is your assessment of how the client is progressing (or not) or what some concerns might be and why. Use abbreviations and medical terminology in this SOAP note. It the symbols arc hard to put in, it is ok to spell them out or abbreviate. S: Client has back pain. O: Upon arrival, client was sitting in wheelchair, in his hospital pajamas and robe, looking at the TV in his room. He started talking to therapist several times, complaining of back pain and stating he felt depressed. He frequently looked at TV while talking to therapist. Client was asked to get ready to get dressed for the day. Client completed upper and lower body dressing from sitting position with a little bit of help. Upper extremity exercises reviewed with therapist and completed. He used both hands together during exercises and lifted arms together approximately 30 times while breathing in and out. A. Client is demonstrating improvement in dressing abilities from moderate to minimal assist this week. P. Continue plan of care.Explanation / Answer
S: The pt. c/o back pain and depression while looking @ TV in his room. He came for the review of PT.
O: Upon arrival, pt. was sitting on a w/c, in his home pajamas and robe. The pt. C/C was backpain.He frequently looked @ PT while raising BUE together during physical Ex. done approx. 30 x with normal breathing. He was asked to change both upper and lower body dresses to see the improvement. He was able to dress up with the help of Assist. in sitting position.He stated this to the therapist several times.
A: His ROS by the PT after completing the UE Ex. in a HEP showed improvement in his dressing abilities from min to mod. with the help of Assit.
P: Cont.P: of care.