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    Pt arrived for their physical therapy session and was able to follow verbal instructions. The pt required a 2-wheel walker and contact guarding for support when walking. They completed the treatment which involved walking 4 meters, turning around, and walking back 4 meters to their chair. The pt dragged their feet when lifting them off the ground but moved at a consistent pace. The pt responded well to treatment and completed the planned activities with verbal cues. Their progression will be reported back to the occupational or physical therapist and treatment will continue as planned.

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    Soap Note

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    api-708264740
    37 views1 page
    Pt arrived for their physical therapy session and was able to follow verbal instructions. The pt required a 2-wheel walker and contact guarding for support when walking. They completed the treatment which involved walking 4 meters, turning around, and walking back 4 meters to their chair. The pt dragged their feet when lifting them off the ground but moved at a consistent pace. The pt responded well to treatment and completed the planned activities with verbal cues. Their progression will be reported back to the occupational or physical therapist and treatment will continue as planned.

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    Pt arrived for their physical therapy session and was able to follow verbal instructions. The pt required a 2-wheel walker and contact guarding for support when walking. They completed the treatment which involved walking 4 meters, turning around, and walking back 4 meters to their chair. The pt dragged their feet when lifting them off the ground but moved at a consistent pace. The pt responded well to treatment and completed the planned activities with verbal cues. Their progression will be reported back to the occupational or physical therapist and treatment will continue as planned.

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    37 views1 page

    Soap Note

    Uploaded by

    api-708264740
    Pt arrived for their physical therapy session and was able to follow verbal instructions. The pt required a 2-wheel walker and contact guarding for support when walking. They completed the treatment which involved walking 4 meters, turning around, and walking back 4 meters to their chair. The pt dragged their feet when lifting them off the ground but moved at a consistent pace. The pt responded well to treatment and completed the planned activities with verbal cues. Their progression will be reported back to the occupational or physical therapist and treatment will continue as planned.

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    November 4, 2023, 1804---------------------------------------------------------------------------------------

    OTA/PTA S/ Pt arrived alone and was able to follow verbal and directional instructions, consent
    was documented and given----------------------------------------------------------------------------------
    O/ Pt was seated in the chair upright upon arrival. Pt was assisted with minimal assistance when
    getting up. Pt did require 2 Wheel-walker (2WW) and contact guarding when walking. Pt used
    directional instructions when showing where to walk. Pt was able to use 2WW and support to get
    in and out of the chair. Pt was able to perform the whole tx which was to walk 4 meters then turn
    around and walk another 4 meters back to the chair. Pt feet were dragging when lifting off the
    ground. Pt was moving at a good and consistent pace. Pt was left sitting up in a chair comfortable
    with a bell by her side in case there was a problem. ----------------------------------------------------
    A/ Pt responded to tx well and was able to perform the whole tx with verbal and directional
    cueing. Pt walked 4 meters forward, turned around then 4 meters back to the chair and was
    seated back down. Pt is improving with tx plan.----------------------------------------------------------
    P/ Report progression and tx back to OT/PT and continue tx plan as followed by OT/PT plans----
    ---------------------------------------------------------------------------------------------------------------------
    -----------------------------------------------------------------------------Tiana Holder, OTA/PTA student-
    ------------------------------------------------------------------------------------**Co-sign by therapist**--

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