SOAP Note Physical Therapy Documentation
Having a lot of trouble creating a daily treatment note in theSOAP note format. Please help create SOAP note for thisscenario.
You are working with an inpatient, John Wort, withGuillain-Barre syndrome. His physician is Dr. Purple and his chartnumber is 9047703526. He reports that he is doing better today withmuch less fatigue after the session yesterday. His therapeuticexercise consisted of ankle pumps, active hip abduction in supine,heel slides, bridging, and knee extension sitting at the edge ofthe mat (4 sets of 10 repetitions each). After the exercises, youworked on functional training including transfers from the bed toand from the wheelchair using a standing dependent pivot transfer.The patient required minimal assistance from 1 person/therapist andyou had to block his knees because of quadriceps weakness. At theend of the session, the patient required moderate assistance of 1person/therapist to transfer back to bed because of mild fatigue.He positioned himself in bed with verbal cues and use of the siderails for assist to scoot. His ability to transfer has not improvedin the last week. The plan is to work on gait training thisafternoon.
