SOAP NOTE 1

SOAP Note

Joshua Wilson

Master of Occupational Therapy, Pacific Northwest University

OTH 510: Intro to Occupational Therapy

Dr. Brandon Imamshah

November 27, 2023

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 2

Client Information

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 3

Name: Bob’Nforapples Age: 72 Date of Service: 09/04/2023

Diagnosis: Left CVA w/ Right Hemiparesis
Medical History: History of heart disease, COPD, left total knee replacement x 5 years ago,
and macular degeneration.
Occupational Profile
Client is right hand dominant and was referred to OT for a L CVA w/ right hemiparesis. He
is a retired naval officer and widower. He lives alone in a 5-step entry/exit one level home.
The client’s interests are drinking Brandy, driving, watching tv, interior/exterior home upkeep,
cooking, and visiting with his daughter. His daughter a single mother works 30mins away and
she visits weekly as his support. Client was (I) in all ADL’s, IADL’s, driving, grocery
shopping, and attending medical appointments before CVA. Client was engaged in church
community before he became a widower. He has become socially isolated from the
community since his wife’s death.

Barriers to recovery are his history of health issues and the effect living alone has had on his
mental health. Client’s primary support is his daughter, and his secondary support is from his
church community. His one-story home is advantageous for his recovery. The client’s
strengths are his motivation to get better, regain his independence, and he maintains physical
capabilities to participate for 5mins in dressing tasks.
Subjective
 “Things are falling apart all around me. I’m not as agile and strong as I once was.”
 “I’m becoming very forgetful, and I know I need help.”

Objective
Occupational Performance-
 Set-up and supervision with self-feeding.
 Min-mod physical A with bed mobility.
 Mod physical A with UB and LB dressing and toileting.

Body Functions-
 Sensation = tactile, thermal, pain sensibility, and proprioception absent throughout
RUE.
 Vision = 50% right visual field cut; reports blurriness and difficulty recognizing
shapes, faces, and color; unable to track object in all visual quadrants.
 Manipulation = unable to oppose digits.
 Endurance = able to participate in five min of dressing tasks (seated and standing) prior
to resting; able to walk 10 feet from bed to bathroom prior to resting.

Performance skills/actions/movements-

Range of motion:

 RUE shoulder AROM = 90 degrees elevation in scapular plane.

 RUE hand AROM = 50% digital flexion, no active extension.
 RUE shoulder PROM = 120 degrees in flexion with empty end feel (pain limited) and
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 4

hypertonic response (guarding) noted.

 RUE hand PROM = full motion noted in flexion and extension.

Client Factors-(Spiritual, Values, and Beliefs)

 Wife died one year ago.

 Married for 30 years.
 Right-handed.
 72 years old
 Retired naval officer.

Assessment
Client had a left CVA resulting in right hemiparesis and decreased active and passive ROM
in(right>left) extremity. Client requires Mod assist in dressing UB and LB and when
performing IADLS/ADLS. Client’s decline in body functions, specifically in manipulation, vision,
sensation, and endurance. His motor function on the affected side is compromised, which is
evident in his difficulties with self-feeding, dressing, toileting, and bed mobility. His vision
limitations further complicate his performance skills and movements. Transportation for the
client will be problematic for rehab. Client requires Mod physical (A) in dressing UB and LB
and when performing dressing and toileting due to left CVA. The client’s potential for rehab is
shown by the client’s motivation to receive education to return home and his commitment to
improving his well-being: “he would do whatever it takes to get better.”, and “he was afraid of
being placed in an “old-folks” home.”
Plan
Skilled OT recommended for client to attend 45mins 3days/week for 6 weeks. Working on
UE strength and ROM to allow more independence in UB and LB dressing. The treatment
will target increase his performance of manipulation, endurance, sensation, and vision with
mod assistance to perform toileting and dressing.
Plan for next treatment (Tx.): Client will warm up on exercise bike for 5mins to increase
endurance. He will work on increasing ROM of right UE with reaching. Exercises will focuses
on manipulation of big/small objects to increase client’s distance between thumb and index
finger.

Targeted Outcomes
Outcome 1: Improvement- Achieving improved occupational performance while coping with
performance limitations through adaptation. Client will participate in strengthening and
stability exercises to increase range of motion to right UE for dressing.
Outcome 2:
Participation- Work engagement that is both personally fulfilling and congruent with cultural expecta

Goals

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 5

LTG 1:
Client will dress UB while seated with min assist using adaptive equipment in 12 weeks.
STG 1: Client will receive verbal cues for UB dressing for 3 days/week for 6 weeks.
STG 2: Client will retrieve dress shirt from closet for 3 days/week for 6 weeks.
Approach to Intervention: Establish/Restore- This approach aims to establish a skill or ability
that hasn't developed or to restore a skill or ability that has been impaired by modifying client
variables. The clients BUE mobility with strengthening and ROM exercises.
Type of Intervention: Occupations- These are daily life events, both broad and specific, that
hold personal importance for the client. The client completes morning dressing and cooking
using PEC w/ flowchart for sequencing.
LTG 2:
Client will be able to sequence ADL’s (Toileting & Cooking) with short- & long-term memory activit
STG 1: :
Client will participate in memory games for sequencing toileting/ bathing 30min/day on Lumosity: Br
training for 6 weeks.
STG 2:
Client at home will sequence how to dress with min-assist verbal cues from daughter via cell phone 3 d
Approach to Intervention: Modify/Adapt- The approach is centered on identifying strategies
to modify the existing context or demands of an activity to facilitate performance in a natural
setting. This could involve the use of compensatory techniques. For instance, certain features
might be enhanced to provide cues, or others might be reduced to minimize distractions. By
simplifying task sequence for client to improve dressing and toileting for home return.
Type of Intervention: Activities- Activities are components of occupations that are distinct and
independent from the client’s engagement or contexts. These activities, when used as
interventions, are chosen and structured to foster the development of performance skills and
patterns, thereby enhancing occupational engagement. The client will choose the order of steps
to make meals with an activity sequence chart. Client will also be sequencing hygiene steps for
before and after toilet use to ensure ability to maintain hygiene before returning home.
Billing and Coding Information
Treatment Code: MB53&XK9K-
I chose this code because the client was diagnosed with L CVA causing R Hemi-paresis.
This code will cover treatments targeting dressing, cooking, and toileting exercises.
Moderate level complexity to challenge the client in activities he enjoys and finds
meaning in.
CPT Code: 97166- Moderate level complexity will allow an analysis of the occupational
profile, analysis of values from assessments. Client also has comorbidities that affect
occupational performance.

SOAP Note Template

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 6

Client Information
Name: Bobnforapples Date of Service: 11/08/23
Diagnosis: Left CVA w/ Right Hemiparesis
Medical History: History of heart disease, COPD, left total knee replacement x 5 years ago,
and macular degeneration.

Subjective
 When asked, “Client expressed difficult control while extending the limb.”
 Client expressed difficulty with extension of R UE.
 Client reports stretching in end range of motion w/o pain.
Objective
Motor Control:
 Facilitation of up righting forearm in flexion/extension
 Controlled extension of vertical arm 2/5times with minimal assistance
 Tactile cueing/support of arm during extension and up-righting
 Increased effortful behaviors noted, including straining sounds, exaggerated
mouth/facial movements, and shortening of breath.
Dressing ADL:
 Facilitated shirt set up with sequence of putting effected side in first.
 Pre-positioning the jacket to allow unaffected arm into jacket first.
 Education on dressing sequenced from shirt to jacket.
 Physical assistance was used for unaffected arm to put jacket on.
IADL:
 Occupation based exercise of washing care with affected hand.
 Active assist with non-affected hand over affected hand with reaching, pulling, and
circumduction at waist level.
 Supported of effected hand while using non-affected hand to wash car at waist level.
 Assisted reaching working at shoulder height to target weight bearing and balance.
 Hand over hand support when reaching midway of hood.
 Supporting
Assessment
Client has expressed difficulty with the extension of the right upper extremity (RUE) (Motor
control), which impacts his ability to perform daily activities. They also display difficulty in
controlling the limb while ‘extending’ during the dressing ADL, which may affect their motor
control and coordination. However, the client reports ‘stretching’ in the end range of motion
(EROM) without pain, indicating some level of flexibility during IADL task. The client has
shown some progress in response to the interventions. The client is able to facilitate up-
righting of the forearm in flexion/extension during bedside exercises. He showed control with
extension of the vertical arm with min. assistance during his jacket donning. The client also
demonstrated increased effortful behaviors when performing IADL of washing car, which may
indicate their determination and commitment to the therapy. The client has made progress in
motor control of RUE with dressing activities of daily living ADLs, with facilitated shirt setup
and pre-positioning of his jacket. The client required minimal physical assistance for the
unaffected arm to put the jacket on. In terms of instrumental activities of daily living IADLs,
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 7

the client was able to participate in an occupation-based exercise of washing a car with the
affected hand, with active assistance from the non-affected hand. The client’s potential for
success and progress is promising. They have shown improvement in motor control and have
actively participated in the therapy sessions. Their ability to stretch in the end range of motion
without pain suggests potential for further improvement in flexibility and range of motion
RUE. The client will benefit from continued occupational therapy, which will facilitate them
improve their motor control, coordination, and INDP in ADLs & IADLs. The therapy will also
provide them with modify/adapt strategies to manage their difficulties with limb extension,
thereby enhancing their overall function and quality of life.
Plan
Client will continue care 5x/wk for 12week of skilled instruction on using PECs and
flowcharts throughout his house for dressing, toileting, and cooking. These exercises will also
target improving ROM and strength for RUE from a home program that will be modeled to the
client.
Billing Information
CPT Code Type of Intervention
97112 Right forearm stability and facilitated extension.
while side lying w/ provided tactile and verbal cues.

97535 Activity of Daily living

97530 Neuromuscular reeducation of movement, balance, coordination,
kinesthetic sense, posture, and/or proprioception for sitting and/or
standing activities

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 8

Discharge Template- (Updated Occupational Profile)

Name: Bob N. Forapples Date of Service: 11/27/2023

Diagnosis: Experienced a left CVA resulting in right hemiparesis
Medical History: History of heart disease, COPD, left total knee replacement x 5 years ago,
and macular degeneration.

Occupational Profile
Client was referred to occupational therapy services after experiencing a L CVA resulting in
R-hemiparesis. At present, the client reports therapy was purposeful and beneficial to his
recovery. He progressed in all areas and would like to continue working towards independence
in the community and engaging in physical activities at home, like gardening, cooking, and
yard work. He enjoys social interactions, playing board games and going on community
outings. He likes eating in the dining hall as opposed to alone in his room.
Summary of Intervention Process
Start Date: End Date: 11/27/2023 Number of Sessions: 60
09/04/2023

Targeted Outcomes: Improvement- Adapting to performance limitations to increase

occupational performance. Exercises will provide strengthening and stability to increase range
of motion to right UE for dressing. Improvement was made by the client increasing
manipulation by 2cm of distance between thumb and index finger to facilitate grabbing
garments when dressing.
Participation- Work engagement that is both personally fulfilling and congruent with cultural
expectations. The client has regained the ability to perform ADLs w/ Mod assist by using PEC
cards throughout the house to become more independent in cooking and toileting. Client’s
participation in using environment modifications (grab bars for sit
to stand and to stabilize in standing while pulling up pants).
Approaches to Intervention: Establish/restore- This approach aims to establish a skill or
ability that hasn't developed or to restore a skill or ability that has been impaired by modifying
client variables. Focusing on muscular endurance and strength of the RUE to enable Mod-
INDP in dressing and cooking.
Modify/Adapt- The approach is centered on identifying strategies to modify the existing
context or demands of an activity to facilitate performance in a natural setting. This could
involve the use of compensatory techniques. Using certain features might be enhanced to
provide cues, or environmental modifications to safely transfer. Simplifying task sequence
with flow chart to improve dressing and toileting for home return.
Types of Interventions: Occupations- These are daily life events, both broad and specific,
that hold personal importance for the client. The client completes morning dressing and
cooking using PEC cards to sequence and adaptive equipment for grips, bends and reaching.
Activities- Activities are components of occupations that are distinct and independent from the
client’s engagement or contexts. These activities, when used as interventions, are chosen and
structured to foster the development of performance skills and patterns w/ reaching and
grasping, thereby enhancing occupational engagement. The client will choose the order of
steps to make meals with an activity sequence chart. Client will also be using environment
adaptations to improve safety when sequencing hygiene steps for before and after toilet use to
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 9

ensure ability to maintain hygiene before returning home.

Data Comparison
Measure Initial Discharge
Self-feeding Set up and supervision Mod INDP (requires extra time
and uses non-dominant hand)
Bed mobility Min-mod physical A Independent with bed mobility
Toileting Mod Physical A Mod INDP (uses grab bars for
sit to stand and to stabilize in
standing while pulling up pants)
Dressing Mod physical A with UB and LB dressing Mod INDP with UB dressing
(uses hemi-dressing technique,
requires extra time, and sits);
Mod INDP with LB dressing
(sits, requires extra time)
Manipulation Unable to oppose digits 2 cm distance between thumb
and index finger
Vision 50% right visual field cut; reports 15% right visual field cut; mild
blurriness and difficulty recognizing blurriness; able to recognize
shapes, faces, and color; unable to track shapes, faces, and colors; tracks
object in all visual quadrants. in all visual quadrants with mild
overshooting
Sensation Tactile, thermal, pain sensibility, and Mildly impaired tactile, thermal,
proprioception absent throughout RU pain sensibility, and
proprioception throughout RUE
Endurance Able to Able to walk 10 feet Able to Able to walk at
participate in 5 from bed to bathroom participate in a slow-paced x
min of dressing prior to resting. 10 min of 10-15 mins
tasks (seated and dressing tasks without rest.
standing) prior to (seated and
resting. standing) prior
to resting.
RUE hand AROM = 50% PROM = full motion AROM = 90% PROM = full
digital flexion, no noted in flexion and full digital motion noted
active extension. extension. flexion in flexion and
25-50% active extension.
extension.
RUE AROM = 90° PROM = 120° in AROM = 120° PROM:
shoulder flexion with empty elevation in the Flexion = 150°
end feel (pain limited) scapular plane; with mild
and hypertonic hypertonic
response (guarding) response;
noted Abduction =
130° with mild
hypertonic
response
Progress Towards Goals
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 10

Goal Progress
LTG 1: Met- RUE shoulder improved
Client will dress UB while seated with min assist using adaptive equipment in 12 weeks.
with AROM 30° and PROM by
30° and added Abduction motion
by 130°. Clients RUE hand
improved w/ AROM improved
by 40° full digital flexion &
gained 25-50% active extension
of fingers. Clients’ endurance
increased in duration of standing
from 5mins to 10mins.
LTG 2: Met- Client improved vision
with a 35%
Client will be able to sequence ADL’s (Toileting & Cooking) decrease
with in long-term
short- & field cut memory activiti
by using PEC cards and flow
chart for sequencing. Client has
progressed to Mod INDP in
toileting w/ using grab bars for
sit to stand and to stabilize in
standing while pulling up pants.
The client also improved
function to Mod INDP with
feeding. Client requires extra
time and uses non-dominant
hand.
Summary:
LTG#1: RUE shoulder improved with AROM 30° and PROM by 30° and added Abduction
motion by 130°. Clients RUE hand improved w/ AROM improved by 40° full digital flexion
& gained 25-50% active extension of fingers. Clients’ endurance increased in duration of
standing from 5mins to 10mins. Client noted that he has made significant improvements in
ability to care for self.
LTG#2: Client improved vision with a 35% decrease in field cut by using PEC cards and flow
chart for sequencing. Client has progressed to Mod INDP in toileting w/ using grab bars for sit
to stand and to stabilize in standing while pulling up pants. The client also improved function
to Mod INDP with feeding. Client requires extra time and uses non-dominant hand. Client
reports that therapy was beneficial because they progressed in all areas of treatment.
Recommendations/Plan
Recommendations for client should continue home exercises, The client has shown
improvement in occupational performance through exercises that provide strengthening and
stability for RUE. It is recommended that the client continues these exercises at home to
maintain/improve the outcomes achieved in therapy. The client has regained the ability to
perform ADLs with moderate assistance by using PEC cards for sequencing. It is suggested
that the client continues to use these cards to maintain independence in cooking and toileting
with twice a week visits from daughter.
Referral for Occupational Therapist (OT) would be beneficial for the client to continue
improving their range of motion and stability with RUE and improve sequencing to be able to
improve longer duration of social gathering. A referral for Speech-Language Pathologist will
PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023
SOAP NOTE 11

facilitate cognition re-testing and can improve or enhance communication skills.

The client should have a follow-up appointment in 4 weeks. This will allow enough time to
assess the effectiveness of the home exercises and the use of PEC cards. The follow-up will
focus on evaluating the client’s progress in performing ADLs independently and making
necessary adjustments to the exercise regimen to reduce the use of PEC cards for sequencing.
The client wants to return home. The duration of the follow-up appointment should be
approximately 1 hour.

PNWU SOT/OTH510IntroToOccupationAndOccupationalTherapy/F2023