Assessment Plan Assignment
Below you will see a summary of two different 1 hour treatment sessions for the same patient as well as a section summarizing the patients information.Please write the Assessment portion of a SOAP note based on how the patient performs from treatment session 1 to treatment session 2. Please also write the Plan section of the SOAP note including at least 2 ideas for treatment. The ideas need to be appropriate for the level of this patient.
Patient Information:Dx: CVA c L hemi. Weakness noted t/o L UE and L LE. Pt does have active movement in her L arm, but having difficulty grasping and manipulating objects. Pt c 3- strength in her L quads and 2 in her L gluts. Her static supported standing balance is F/F+, however, her dynamic supported standing balance is P. She is using a LBQC for amb.
PMH: HTN, CAD, NIDDM, S/P THR in 2009
Home Information: One story home with 3 STE with no HRs
Social Information: Pt likes to play golf.
Treatment Session One: January 31, 2010 at 1:32 p.m.
Pt arrived to Rx session in a w/c. She was not feeling very well. She said she was feeling very tired; hadnt slept well the night a. Pt noted to be very quiet t/o Rx session, and appeared sad. The Rx session began with PTA t/f pt ? mat with pt using her LBQC. PTA had to give mod.PA. PTA noticed that pt puts all of her weight through her R LE and pushes post.during sit ? stand. Once pt is on mat, PTA works c pt doing repeated sit ? stands focusing on proper technique. PTA then has pt step ? on 4 step c R LE and reach ? and ? for bean bags c L UE, and toss into container. Pt needed to rest after about 10 bean bags for each of attempts totaling 4 attempts because of fatigue and SOB. O2 sat was89% after 1st attempt and noted to be 92% within 1 minute of sitting. PTA completed gt. training having pt use her LBQC. PTA had to give mod. max. PA. Ptamb 25, was unable to advance her L LE I, consistently looked down and hyperextension of her L knee was noted 75% of the time. 1 significant LOB noted when pts family arrived and pt turned her head to the L. After gt.training, PTA took pt back to her room.
Second Treatment Session: February 1, 2010 at 2:40 p.m. Pt arrived to Rx session in a w/c feeling better this date. Stated she slept much better last pm. The Rx session began c PTA t/f pt ? mat using LBQC. PTA had to give mod PA. PTA noted pt to have some post. pushing and pt putting more weight thru L LE during
sit?stand. PTA continued to have pt. practice sit ? stands at varying heights. PTA also had pt put R LE on 4 step and throw ball against a wall at various targets. Pt noted to be SOB with activity, taking frequent rest breaks. O2 sat 93%. PTA ended Rx c gt. training using LBQC. Pt having difficulty remembering what foot to move first. Pt looking down less with VC and TC from PTA. Pt starting to advance L LE on her own, however, PTA still needing to clear her L foot. Pt amb 30 c mod PA max PA from PTA, and pt able to control knee better. Pt not sad during any of the Rx session. P Rx was done, PTA took pt back to room.