Courtney McDonald

FW SOAP NOTE
3/2/2016
S: Pt initially reported that she wanted to shower.
O: Pt was seen on telemetry unit of Davis Hospital to treat generalized weakness
following seizures. Pt required min A to ambulate between bed and shower and to
transfer to shower chair. She needed mod A to sit EOB, doff gown, and bathe. Pt
needed max A to doff brief and socks, and don clothing. Caregiver education was
provided on how to help pt and possible options for d/c. Caregiver was encouraged
to talk to social work about concerns about pt living at home.
A: Pt fatigued quickly while showering. She needed assistance while bathing and
dressing due to fatigue, poor balance, and decreased shoulder ROM. She needed
min A while ambulating and sitting EOB due to balance and safety concerns.
P: Skilled occupational therapy to continue 5x/wk for 10 days. OT recommended
SNF to MD for pt d/c location.

LTG 1: In 10 days, pt will shower with min A.

STG 1: In 5 visits, pt will wash her back with mod A.
LTG 2: In 10 days, pt will complete LE dressing with mod A.
STG 2: In 5 visits, pt will doff socks using adaptive equipment with mod A.