SOAP Note - Northern Utah Rehab Hospital

Jackson Ball
3/27/19

Subjective: Patient ℅ pain in both ankles and R hip.

Objective: The patient was seen in inpatient rehab at Northern Utah Rehabilitation Hospital in

order to improve functional activity tolerance and functional mobility during ADLs. In his room,

the patient required modA to move both legs to the EOB. The patient required minA to move

from supine-to-sit EOB. The patient required CGA to sit-to-stand from EOB to walker and to

transfer from standing into w/c while demonstrating safe technique. The patient is modI to

ambulate for short distances with a 2WW. In the therapy gym, the patient transferred from w/c to

edge of mat with minA. The patient required use of a leg lifter and modA to place both legs on

the mat and to move from supine to sitting EOB. During bed mobility exercises on mat, the

patient completed 4 sets x 5 reps supine bridges with a bolster under his hamstrings.

Assessment: The patient demonstrates low activity tolerance and limited mobility due to pain,

obesity, decreased strength, decreased joint ROM in UEs and LEs, and decreased

cardiovascular endurance. The patient requires frequent rest breaks during activity and is a fall

risk in standing. The patient is making progress towards goals due to increased training in the

use of AE and improved strength and endurance as a result of engagement in therapeutic

activity, exercise, and self-care training. The patient is not yet safe to engage in activity and

complete ADLs with modI.

Plan:

The patient will benefit from continued skilled OT services 1-2x a day for a total of 90 minutes,

5-6x a week, in order to improve functional activity tolerance and completion of ADLs.
Goals:

LTG: In two weeks, the patient will don/doff crow boot and darco boot with AE while seated in

w/c to improve performance with LB dressing.

STG: In one week, the patient will independently manipulate reacher to undo velcro straps of

crow boots in order to improve performance with LB dressing.

STG: In one week, the patient will place foot in crow boot with modI in order to improve

performance with LB dressing.

LTG: In two weeks, the patient will complete toileting with modI.

STG: In one week, the patient will independently use AE to maintain proper toileting hygiene.

STG: In one week, the patient will perform toilet transfers with CGA in order to improve

independent performance of ADLS.