SOAP Note #2 OSU Acute Care Emma Sabransky

S: Pt stated that he had no pain and was feeling well enough to complete ADL tasks at the sink instead of
at bedside.

O: Pt participated in 40 minute OT session in hospital room for completion of morning dressing and
grooming. Pt presents with decreased dynamic standing balance, particularly while ambulating,
decreased endurance/activity tolerance, and decreased insight into deficits.
Functional Mobility: Pt required SBA and 1 verbal cue to transfer from supine to EOB. Pt required CGA
to stand from EOB, ambulate to sink, and ambulate from sink to bed but performed stand to sit transfer
with SBA. Pt continued to require SBA and 1 verbal cue to transfer from EOB to supine in bed.
ADLs: While seated EOB, pt required min A to doff old gown and don new gown. Pt required SBA to doff
old socks and don new socks, assuming a figure-4 position with no difficulty. Pt was able to pick up old
socks from floor with SBA. While standing at the sink (8 minutes), pt participated in various grooming
tasks, including washing face and brushing teeth, with set-up and CGA. Pt required increased verbal cues
for processing, sequencing, and problem-solving for completion of tasks. Specifically, pt required verbal
cues to stop applying soap to washcloth, to stop washing/drying face, and to stop dispensing toothpaste
onto toothbrush as he appeared to become perseverative. Overall, pt presented with decreased
attention to task during ADL participation.

A: Pt deficits in dynamic standing balance and endurance/activity tolerance limit pts ability to complete
basic self-care tasks and safe transfers. Decreased pain resulted in pt being agreeable to therapy and
able to complete ADL tasks at the sink versus at bedside. Pt would benefit from continued instruction in
safe transfers to increase safety while completing ADL tasks.

P: Continue to treat pt 5x/wk for duration of hospital stay for skilled instruction in safe transfers and ADL
retraining. Plan to address dynamic standing balance and endurance/activity tolerance to increase
independence in grooming and bathing.