28 Mar Let’s make this a bit more realistic. Here is a
Let's make this a bit more realistic. Here is a link to a sample treatment session where you get to be the PTA writing the Interim SOAP note (Not Initial).
Watch the video, take notes, and write the SOAP note.
Make sure to look at the grading rubric, the Erickson text, and your SOAP note fact sheet as guidance. If you do this, you will do quite well on this assignment which is due on Monday at 11:59pm.
https://www.youtube.com/watch?v=kEZvWcSLcVc
example below
Diagnosis:
Wellness Service Start Date:
Session #:
Today’s Date:
Precautions:
S:
O:
Data Collection:
BP:
HR:
RR:
O2 sats:
Girth Measurements:
Therapeutic Exercise: Examples of format and how to write out exercises.
HEP: Was it reviewed? What exercises? How many reps? Quantify v/c or t/c needed (% of time or min, mod, max).
Supine:
· Bridging 3×10 reps and min v/c for increased hip extension AROM
· Ankle pumps, QS, glute sets 3×10 reps
Seated:
· B LE LAQ 3×10 reps with min v/c for improved eccentric control
· B UE scapular row 2# t-bar 3×10 reps
Standing: All exercises performed in // bars or EOB, etc. and include assist
· Mini-squats c light B UE assist, 2×15 reps, SBA for safety, v/c 50% of time for proper technique
· B LE hip ab/ad 3×10 reps, SBA
Therapeutic Activity:
· Dynamic stand bal. on foam mat tossing ball, x3’, CGA, LOB 25% of time
· Monster walk c light orange resistance band at ankles, 20’x4 reps, SBA, v/c 20% of time to increase stride length, no LOB noted
Neuromuscular re-education:
· Unsupported static balance EOB x7’, Mod Ax1 to prevent posterior lean/LOB, v/c and t/c 75% of time
Gait Training:
· Amb s AD, SBA 150’x2, forward flexed posture at trunk, v/c 25% of time, no LOB noted
· Amb c B UE canes to promote reciprocal arm swing, CGA 150’x2, no LOB noted
Manual therapy:
· B LE passive HS stretch 3×10 sec holds
· STM to R upper trap x15’
· STM/cross friction, to anterior L LE TKA incisional scar.
Physical Agents:
· US R lat. knee, LCL, supine, 0.5 W/cm2, pulsed 20%, 3MHz, 5min.
A: Focus on 1-2 areas of the tx session, try to limit to 3-5 sentences and provide evidence to back up why therapy is indicated. Also keep in mind this is a legal document and the insurance company will approve more tx visits based on your assessment.
Ex: Pain decreased following today’s session. Attempted LAQ with ankle weight on L LE, exercise was modified due to leaning compensatory strategies through ROM secondary to L LE weakness. Client tolerated supine manual HS stretch well, may benefit from contract relax supine HS stretch to assist with decreasing LBP and promote improved postural alignment which will increase daily functional abilities. Client required mod v/c to maintain upright posture for seated HS stretch and extend knee. Client will benefit from cont education on proper form/technique with seated HEP HS stretch.
Goals: copy and paste from initial evaluation, address in the assessment if any goals were met and if new goals are written (by the PT).
Ex. of how to address a goal that’s been met.
1. Client will amb c FWW 150’x1, min Ax1, LOB <50% of time. GOAL MET
Revised goal (by the PT): Client will amb c FWW 150’x1, CGA s LOB.
P: The plan gives direction to the next therapist. What should they continue to work on, should they advance an exercise, is more pt. education needed and in what area, etc?
Example:
Review HEP monitoring for correct posture and technique. Progress to contract/relax supine HS stretch to increase flexibility for decreased LBP. Continue working sit/stand on low surface heights to gain proper form/decrease LBP.
Billing: Description and Units
Remember CARE Clinic “bills” in 15’ units, and we see clients for approx. 1 hour.
Example: 1 TA, 1 TE, 2 GT
Signature and Date:
Mark Smith, SPTA 9/4/2019
,
PT 105 Unit 4 SOAP Note Midterm
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PT 105 Unit 4 SOAP Note Midterm |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeSubjective Data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) PT105-CO2 |
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5 pts |
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This criterion is linked to a Learning OutcomeObjective Data (Relative to the information documented in the CC, HPI, PMH, and ROS) PT105-CO2 |
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5 pts |
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This criterion is linked to a Learning OutcomeAssessment (Information documented in the CC, HPI, PMH, ROS and the objective data.) PT105-CO2 |
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5 pts |
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This criterion is linked to a Learning OutcomePlan (Demonstrate application of current clinical practices for the identified assessment designations, and demonstrates congruence of information across all aspects represented.) PT105-CO2 |
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5 pts |
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This criterion is linked to a Learning OutcomeWriting |
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5 pts |
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Total Points: 25 |
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