SOAP NOTE

October 5, 2020 -----------------------------------------------------------------------------

16:30 OTA/PTA -----------------------------------------------------------------------------

Subjective (S): Patient (Pt) did not speak during treatment session, and
gave non-verbal consent to proceed in today’s treatment session 1. -----------

Objective (O): Pt went from sit to stand with minimal one-person

assistance onto a Low Wheeled Walker (LWW). Pt ambulated with LWW
and with minimal one-person assistance in one direction starting with the
right lower extremity. Pt ambulated 22 steps in one direction. Pt made a U-
turn with the LWW and with minimal one-person assistance to face the
opposite direction. Pt ambulated with the LWW and minimal one-personal
assistance in the opposite direction, starting with the right lower extremity.
Pt ambulated 22 steps in the opposite direction. Pt made a U-turn to face
the initial direction. Pt went from stand to sit from the LWW with minimal
one-person assistance to sit on their initial chair. Pt is left sitting in a chair2.

Analysis (A): Pt responded to verbal and non-verbal cues to ambulate in

one direction and then the other. Pt tolerated the treatment and followed
instruction effectively. Pt is left sitting in a chair at the end of the session 3.
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Plan (P): follow up with the progress of the treatment session to the
Occupational Therapist (OT) and/or Physiotherapist (PT), and continue the
treatment plan under the OT/PT’s plan. -----------------------------------------------

-----------------------------------------------------Name/Signature: Aryana Indarjeet

-----------------------------------------------------Co-sign by Therapist: ---------------