Client Name:

Client date of Birth:

SOAP NOTE

27 Dec/2017 OTA & PTA-S/Pt was sit down in the wheel chair. Pt was verbal during tx session.
- O/Consent documented on the file. Pt seen for tx session for walking mobility using 2-
wheel walker with the 1 assist. Pt transferred sit to stand with 1 assist on her right-hand
side. Pt starts to walk with 2ww and 1 assist x 20 steps using three steps pattern. Pt turn
around and ambulated with 2ww and 1 assist on right side x 20 steps. Pt transferred in the
power wheel chair with 1 min assist. Pt is sit down in the powered wheel chair. Pt
motivated during tx session. _______________________________________
- A/Pt responds to the verbal and minimal assistance to walking. Pt tolerated tx session
well. _________________________________________________________
- P/Progress report send to OT/PT and continue per OT/PT therapy plan.
_______________________________________________________________

___________________________________________ Beenal Patel OTA & PTA

Student of Durham College
Cosign by Therapist.