Blaine Huffman

SOAP Note 3

Client: L

LTG: By d/c, client will independently make a 6 or more step meal using a compensatory strategy

STG: In 4 weeks, client will make a meal using the stove top with min A for safety concerns

S: “Using this post it note helped out a lot”

O: Client planned ahead with materials needed for cooking chicken fajitas and brought all ingredients,
pans, and utensils. The client was familiar with this recipe and read the instructions prior to our session.
Client was educated about strategies to plan a successful environment by eliminating distractions. The
client was also educated to follow instructions more efficiently and address divided attention. During the
task, the therapist attempted to talk to the client during the task. The client identified that the
distraction and asked the therapist to wait a minute to talk to him until he completed the current step.
Client elected to use the strategy of using a post-it note for marking location in steps. Client
independently placed post-it note on recipe and independently gathered ingredients. The client used
the compensatory strategy and did not reread completed steps or read past the current step. However,
the client required two direct verbal cues to remember to refer to the instructions. During the cooking
client required 3 indirect verbal cues for safety as the client forgot to turn the burner off and placed a
paper plate near the heated burner.

A: The client was able to improve his divided attention and efficiency following instructions by
implementing the strategy of using a place holder. This allowed the client to complete a step and return
to the instructions without losing his place. He was able to concentrate on the current step without
having to also focus on finding his place in instructions. The instructions and recipe were also familiar to
him which decreased the demand of divided attention during the task as he could remember some of
the order of the steps. However, as the client needed cueing to remember to check the instructions
throughout the task and to pay attention to the burner or other safety concerns, there is still need for
improvement for divided attention. From the observation of the task and needed cueing, the client
would still need assistance in completing a novel or unfamiliar task. Skilled OT services are still needed
to achieve goals.

P: Skilled OT services will continue to be provided to address divided attention, processing speed, and
safety concerns during cooking. Additional compensatory strategies will be discussed and implemented
in novel and unfamiliar tasks in order to generalize improved skills.