REVISED SOAP NOTE

Client: BROWN, Rose

BRN: 14672
Phone: 111-222-3333

On October 7th, 2019 (S) The patient presented to be motivated as there was not much difficulty to being the treatment.. The

patient then gave consent to start the treatment and stood up out of her wheel chair. The client presented calm and relax prior to

her treatment. (O) The patient started off sitting on a power walker. The PT assisted the patient in stand up, and transferred from a

power chair to a 2- wheeled walker. The patient required a minimum 1 assist, as the patient walked 20 steps in either direction of the

room. The patient used a step through gait patter with a min x 1 assist. The PT supports the patients lower back and chest with hands

his hands as a barrier. The patient right foot is jerky during the exercise due to the weakening of the muscles. The patient took short

and small steps, and needed assistance when pivoting to change walking directions. The PT held onto the back of the patient

supports to help with stability and tactile cues of when to pivot. (A) the patient responded well to all instructions for the therapy plan.

Minimal x1 assistance to transfer to/ from power chair and to ambulate 40 steps total with a 2 wheeled walker. (P) progress report to

the OT/PT and to continue the therapy plan for the patient. ---------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------Natalia Perry, OT/PT clinical notes

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