Date: 2/12/2020

Name: R

Diagnosis: Right Hemiplegia, Right Shoulder Subluxation, Expressive and Receptive Aphasia

Occupational Therapy SOAP NOTE

S: When asked if client felt pain as his right leg was being stretched, client responded “yes.”

O: During session, client was asked to copy the movements of a Pilates instructor for 60 minutes. These
movements included bilateral and unilateral actions of his upper and lower extremities such as bridging
exercises, heel to toe movements, and exercises demanding flexion, extension and abduction of his
shoulders. Client required Max VC, 10-12 times, to understand which movements he was asked to do by
the instructor. He required Max A to move his right upper and lower extremities like the instructor. He
completed a modified form of movement approximately 6-8 times, for positions that were too difficult.
As client right shoulder was being stretched, he expressed that he was feeling pain. He required Min A to
appropriately move his left upper and lower extremity throughout the session and to maintain isometric
positions.

A: Client was seen at the Life Skills Clinic in a ​Mastering Meaningful Movement​ class to address deficits
related to his diagnosis of right hemiplegia. He demonstrated some body awareness; this was indicated
when he verbalized that he was in pain from maintaining certain positions and being stretched too far.
He has subluxation so when moving his right shoulder, proper precautions needed to be taken to
prevent impingement and pain. Him verbalizing when he was feeling pain was helpful to gauge how far
he should be stretched. His spasticity prevented him from being able to have the same range of motion
in positions as the instructor so modified positions were often used instead. Weakness in his left
extremity makes it difficult for client to maintain isometric positions so assistance was required to help
him engage in these exercises. Several VC was required for client to understand which movement he
needed to perform due to deficits relating to aphasia.

P: Client will be treated for 60-minute sessions 1/week for X10 weeks to address motor control deficits
and spasticity. This will help with occupational performance in areas such as ADLs and IADLs. Skilled OT
services are required for appropriate grading of activities that will address performance deficits due to
his diagnosis of hemiplegia. Client’s complex condition requires advanced clinical judgment to adjust the
presentation of activities that will properly challenge him while also teach him to generalize strategies
beyond the treatment session.

Client is an excellent candidate for progress with OT services. Thank you for the opportunity to assist
him in returning to independence in his occupations.

Signature: Blondine Jean