Krista Kowalchik

U0613426
Fieldwork SOAP Note- Spring 2016
S: Pt asleep in bed, hunched forward to right side surrounded by ten pillows. Pt
awoken and reports 7/10 pain.
O: Pt independently demonstrated bed mobility. Refused gait belt for ambulation. Pt
performed sit to stand with modified independence. Pt ambulated simulated home
distance from couch/bed to bathroom (~10 ft. 20 ft. total) using FWW. Pt 100%
compliant with NWB R LE precautions throughout activity.
A: Pt participated and tolerated OT generally well for home safety simulation task.
Pts greatest barrier to participation is pain, which increases over time when R LE is
in dependent position. Pt had to quickly return to bed during activity, and although
he was moving more quickly due to pain, pt maintained weight bearing precautions
and safety the entire task.
P: Pt will continue to participate in skilled occupational services 3-5X/week for two
weeks or until OT goals met. Recommend home safety evaluation prior to
discharge.

LTG: In two weeks, pt will perform LE clothing and brace management utilizing
modified independence.
STG: In one week, pt will independently use dressing AE appropriately.
LTG: In two weeks, pt will complete bathing tasks with modified independence using
DME and compensatory strategies while demonstrating safety awareness.
STG: In one week, pt will independently demonstrate competence in preparing
braced R LE for shower.