SOAP note 4

Client’s name or initials: N.L.

Date of report: 2/7/19

Date of referral: 1/17/2019

Date of birth &/or age: 09/04/1949

Primary intervention diagnosis/concern: L CVA in March 2017 with R hemiparesis.

Precautions/contraindications: Requires cane or walker for functional mobility around her

apartment and motorized scooter for longer distances.

Medications: Baclophen, Metroprolol, Norvasc, Atorvastatin

Reason for referral to OT: Right hemiparesis impacting her ability to complete preferred IADLs.

Therapist: Lauren Beck, OTS

N.L. was seen on Thursday, February 7, 2019 in the Life Skills apartment at the University of
Utah for 60 min. Goals addressed in this session:

LTG 1: By discharge, client will use compensatory strategies to independently attend

community events using adaptive equipment for mobility.

STG 1: In 4 weeks, client will implement use of alternative transportation to facilitate independent
attendance of social events.

LTG 2: By discharge, client will independently incorporate her RUE in order to complete basic
home maintenance tasks using adaptive equipment for mobility.

STG 2: In 4 weeks, client will independently manage muscle tone in RUE to mend clothing with the
use of adaptive equipment.

*This short-term goal was changed to “manage muscle tone” since it is unrealistic to decrease muscle
tone. Muscle tone can be managed in order to more fully participate in activities.

S: While learning a self-range of motion routine, client stated, “Oh, I can see how this will really

help me reach.”
O: Employment: N.L. started new employment at 24-hour fitness and is taking paratransit to get

there with no reported problems.

Self-ROM: Client presented with high tone in RUE, she held her elbow bent at 90 degrees tight

to her chest with her hand in a fisted position. Active range of motion was conducted on

shoulder, range of motion in shoulder is good. Client was instructed on a self-range of motion

routine and given self-range of motion educational materials with descriptions and images to

take home. Passive range of motion and self-range of motion was performed on each joint of R

UE for a total of 30 mins. Client was then able to access some movement in elbow, wrist, and

fingers.

Sewing activity: N.L. independently unscrewed/screwed embroidery hoop, placed fabric in

hoop, pressed top portion of embroidery hoop on top of fabric, and pushed and pulled

threaded needle through felt with left hand. With verbal cues to incorporate right hand, she

pressed on top of hoop during set up and held embroidery hoop in right hand while sewing.

N.L. was instructed on using an adaptive strategy to thread the needle in order to safely

incorporate her right hand. She placed a cork in her fisted right hand then pressed the needle in

the cork and threaded needle with the left. N.L required moderate verbal cues to extend right

elbow during sewing activity. N.L. independently used left hand to make various large and small

stitches. N.L. stated she could use the same strategy to mend her socks at home.
Functional mobility: N.L. did not bring a cane to the clinic today. She rode a motorized scooter

down the hall and used the handles to stabilize herself while moving from scooter to therapy

mat.

A: N.L. is progressing towards her goal of attending community events independently as

demonstrated by her ability to take paratransit to her new employment.

High muscle tone continues to inhibit performance in many ADLs and IADLs. Learned nonuse of

RUE is contributing to high tone. High tone is limiting movement of R UE. Passive range of

motion and self-range of motion are successful strategies to manage her tone and prepare for

activities of daily living.

Client continues to exhibit interest incorporating R UE into everyday tasks. She is receptive to

learning new ways to incorporate her R UE. Currently she is finding it difficult to generalize

strategies from one activity to another. N.L. will benefit from doing activities at the life skills

center that incorporate her R UE in order to learn new strategies and increase her problem-

solving skills.

P: N.L. would benefit from continued occupational therapy (OT) services for task specific skills

training to increase her motor control in ADLs and IADLs. A variety of activities will be

presented to N.L. in order to teach her various ways of incorporating the R UE. Client

will receive skilled OT service in the University of Utah Life Skills Center for 60 min sessions

once a week until March 7, 2019.

Therapist: Lauren Beck, OTS

Date: 2/7/2019