Write an objective statement for your soap note

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Reference no: EM133522851

Documentation in Occupational Therapy

1. Directions

Review the case study for Mary below. Then , plan a 45-minute treatment session for Mary. Include treatment codes for each activity, as well as units/minutes. Also, for each activity, write objective statement for your SOAP note that de-emphasizes the treatment media and highlights function.

Mary

You are an OTA in an out-patient clinic. You are seeing your client, Mary, s/p CTS repair. MD orders are as follows: PROM/AROM to (L) wrist. No pushing or pulling. Splint to be worn 24/7 outside of therapy.

Her goals are to return to work at PLOF as a cashier, complete meal-prep for her family, and drive her stick shift car.

2. Directions

Review the case study for Maude below. Then , plan a 60-minute treatment session for Maude. Include treatment codes for each activity, as well as units/minutes. Also, for each activity, write an objective statement for your SOAP note that de-emphasizes the treatment media and highlights function.

Maude

You are an OTA in a SNF. You are seeing your client, Maude, s/p (L) TKA. She also has mild dementia. Her spouse visits daily and is involved in her treatment. She is CGA for all mobility using a 2ww. D/c plans are for her to return home with her husband's assistance.

Her goals are to complete full AM ADL with supervision and increase SFR score from 5 inches to 10 inches.

3. Directions

Review the case study for Sam below. Then , plan a 60-minute treatment session for Sam. Include treatment codes for each activity, as well as units/minutes. Also, for each activity, write an objective statement for your SOAP note that de-emphasizes the treatment media and highlights function.

Sam

You are an OTA working in an ALF. You are seeing your patient, Sam s/p (L) CVA. Your patient also has COPD and is on 2L of O2 per NC.

RUE is flaccid. PROM is WFL for all joints on all planes

2+pitting edema to RUE below the elbow

Activity tolerance is poor. Cl. requires multiple seated rest breaks with min level ax.

Min (A) with w/c mobility d/t fatigue and difficulty maneuvering in tight spaces.

The treating PT has plans to trial a quad cane, however d/t decreased safety and fatigue this has not been implemented.

His goals are to complete BADLs seated sink side mod (I), transfer with SBA to the toilet and w/c, and complete SROM (I) to LUE.

Reference no: EM133522851

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