Documentation should be concise

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In the example below, all the information is relevant, but does not form a coherent whole. It's not wrong and better to write more than less but documentation should be concise. You are practicing slide board transfers with another client. During an occupational therapy intervention session, you record all of what the client talked about: Client told OTA she has had bad arthritis in her R shoulder and L knee Client rates pain at the site of her R BKA as 8 out of 10 Client said, "it hurts to stand on my left leg." Client stated, "The sliding board needs to be moved further up on the seat." When asked if she was okay after the transfer, she said "I'm just tired" Client stated, "I'm through" and requested help to get closer to the bed When client transferred to the bed for dressing tasks, she said "this is the hardest part." Client states she prefers to transfer toward the R side so she can push off with her L LE and avoid bumping her R BKA on the tire-rim on the w/c. Using these statements, write your own concise and organized version for the "S" portion of the SOAP.

Reference no: EM133808088

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