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Clinical Documentation: The SOAP note
__PART 1__

Please read the following SOAP notes and correct at least one error that you identify. This note has major flaws in clinical reasoning. What does this note need to make it better?

S: Pt. is a 78 y/o female with c/o L CVA and R hemiparesis. Pt. reports stiffness in L hip, but improvement from previous pain report. She states that a she has a preference for transferring with her L LE and uses a hemi walker. Pt states that she is willing to "do whatever it takes to get back home."

O: Pt. is SBA for stand pivot xfer. Pt. in Min A for toilet xfer. Pt. is PWB through R LE. Pt. is I in w/c mobility.

A: Deficits noted in R UE coordination. B UE MS is WFL and dynamic standing balance is P+. Pt. is I in UB dressing p s/u and is able to don pants with Mod A. Pt. is Min A with R sock when using a sock aid. Pt. is I with bed mobility and would benefit from additional skilled OT.

P: Pt. is I with using the reacher to grab things from low surfaces. Pt. to be seen bid for 30 minutes per session to continue to work on neuro re-education strategies and UB dressing. I think that Pt. should also work on UB WB strategies while standing to minimize the pressure on LEs.

WHAT WOULD YOU FIX? (Please comment and don't forget to put your initials after your post!!)

__PART 2__

Please share a website with your classmates that you found helpful in learning more about SOAP notes. Then, review a website that a classmate has suggested. (Don't forget to put your initials after your posts!!). I have posted one to start the thread.

1. http://medinfo.ufl.edu:8050/year1/epc-old/soap_note_handout_06.pdf This is a great ppt presentation. Enjoy. BE

__PART 3__

Watch the YouTube video provided in the course site and email me the final draft of a SOAP note based on the video. This assignment is due no later than 12:00 am on January 15, 2012.