Shawnee Burnett

SOAP Note

Janis Melbourne 45 y/o

S: Client stated that she hates to be away from work and wants to fire her husband from
completing housework. Client has a cheerful affect and was willing to complete the assessment.
O: Client was assessed using and in home observation of simple meal preparation, PASS and
COPM over two sessions to determine competency in and satisfaction in performance of IADL,
ADL, and other occupations.
Occupational Profile
The client lives at home with her husband and her 15 year-old son. She had a RCVA 4 weeks
ago and has just completed inpatient rehabilitation and is beginning outpatient occupational,
physical, and speech therapy. Prior to her injury, she was independent in dressing, household
management, driving, and IADL. She worked full time as a paralegal and wants to return to work
within a few months. Her husband has 3 weeks off of work for part of her rehabilitation, but will
be returning to work full time and the client will be home alone. Her husband is currently
managing household chores and cooking. She currently is independent in dressing in pullover
shirts/sweatpants and slip on shoes. She requires VC to dress in preferred UE clothing. She has
difficulty completing bilateral activities, such as cutting, dressing, and other IADL. She is WFL
for RUE and RLE and has mild weakness in her L trunk and LLE. In her LUE she has 45
degrees shoulder flexion, 60 degrees shoulder abduction, ROM elbow flexion, no elbow
extension, full gross grasp, and no finger or thumb extension.
COPM chart
Occupational Performance Problems
Medication Management
Return to Work
Shower/Dress
Household (bills and cleaning)
Time with dog

Performance
8
3
7
7
1
26

Satisfaction
8
2
5
2
1
18

5.2

3.6

TOTAL
AVERAGE
PASS
The PASS assesses a clients ability to adequately, safely, and independently participate in
occupations. It uses a hierarchy of cuing to grade the level of assistance required by the client
to determine these scores.

Independenc
e
Safety
Adequacy

Medication

Shopping
2

Flashlight
Repair
1

BADL
Dressing
2.56

2
2
1

3
2

3
1

2
1

Client required cues to attend to the shopping task, follow exact directions (verbal and written),
use LUE, problem solve tasks, and correctly manage money. She was frequently distracted by
objects near her or that she was interacting with. She was occasionally disoriented about the
date. She was able to manipulate task items with her right hand effectively. She required
physical support for bilateral tasks. She was unsafe when distributing pills (on the wrong days
and times) and completing LB dressing (standing up while donning and doffing pants). She
required cues to cease a repetitive behavior. She took longer than average to complete the
flashlight repair, dressing, and medication management tasks.
Environmental Observation
The layout of the clients kitchen is primarily conducive to effective mobility and cooking. There
is sufficient space to maneuver a wheelchair and access every major appliance, except for the
freezer, which is on the ground level. The counters are too high for the client while she is in her
wheelchair, although she is still able to use them for cutting. Multiple cupboards are inaccessible
due to their height. The dishes are stored in a cubby on the counter and the client struggles to
access them because of the height of the counter. The fridge is easy for the client to open, as it
has two doors that open without hitting her wheelchair. Under the fridge is a freezer drawer,
which the client would not be able to open because it is so low. The house is a split level, which
makes it difficult for the client to get inside with a wheelchair. Client has a supportive husband,
who has taken over household management tasks.
The client completed simple snack preparation. She required mod direct VC to attend to
retrieving ingredients, items in her left visual field, and preparing the snack. She required mod
VC to cease perseveration on cutting cheese, opening drawers, riding in circles, and stacking
cheese on the crackers. She required min VC to safely use her wheelchair. She was able to
independently open 3 packages, drawers, cupboards, and the right side of the fridge. She
required min A to turn her wheelchair once.
Supports and Barriers/Strengths and Weaknesses
Client is supported by her family, insurance to pay for services, open kitchen layout, w/c, and
medical leave from work. She is inhibited by high cupboards and counters, freezer drawer, split
level home, husband returning to work, and limited number of visits.
Client is very self-motivated, has a good temperament, believes that she can improve, is able to
hold a socially appropriate conversation, has GM and FM skills in RUE, and has GM skills in
RLE. She struggles with hemiplegia in her LUE and LLE, attention to task, perseveration, left
inattention, heeding directions, problem solving, and orientation.

A: Client struggled to complete bilateral tasks secondary to hemiplegia in RUE. She struggled to
attend to and complete various tasks in a timely manner secondary to poor attention, mild left
neglect, poor problem solving, and perseveration. She struggled with w/c safety secondary to
poor attention and safety awareness. Her disorientation to the date may be due to poor memory
or poor attention. She was able to complete tasks that required only one arm without physical
assistance due to strength and ROM being WFL in RUE. Client demonstrates good
rehabilitation potential as demonstrated by motivation to return to work and be independent,
improvement in inpatient rehabilitation, and a supportive family and home environment.
P: Client will required skilled occupational therapy three times a week for 4 weeks for 60 min in
order to improve performance of bilateral tasks, household management, ADL, and IADL.
Occupations and preparatory tasks will be used to address these problem areas.

LTG 1
Within 4 weeks, client will independently dress in preferred clothing within 2 minutes.
Within 2 weeks, client will fasten button up shirt and slacks with min VC for using left hand to
stabilize.
Within 2 weeks, client will use hemi-dressing techniques to thread left and right arms through a
button up shirt within 2 minutes.
LTG 2
Within 4 weeks, client will independently take her pills at the correct time for 2 consecutive days.
Within 2 weeks, client will open her pill bottles with min VC to use LUE to stabilize.
Within 3 weeks, client will use memory strategies to take her pill at the correct time with min VC.