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    The patient arrived for their session in a happy mood and ready to participate. During a two-minute walk with a two-wheeled walker and moderate assistance, the patient walked about 15 feet and was able to turn around independently. The patient demonstrated progress in getting out of their chair and walking with minimal support. They responded positively without complaints of pain. The plan is to continue the current goals and treatment plan, report progress to the occupational therapist, and schedule the next session.

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    The patient arrived for their session in a happy mood and ready to participate. During a two-minute walk with a two-wheeled walker and moderate assistance, the patient walked about 15 feet and was able to turn around independently. The patient demonstrated progress in getting out of their chair and walking with minimal support. They responded positively without complaints of pain. The plan is to continue the current goals and treatment plan, report progress to the occupational therapist, and schedule the next session.

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    24 views1 page

    Soap Note

    Uploaded by

    api-710626507
    The patient arrived for their session in a happy mood and ready to participate. During a two-minute walk with a two-wheeled walker and moderate assistance, the patient walked about 15 feet and was able to turn around independently. The patient demonstrated progress in getting out of their chair and walking with minimal support. They responded positively without complaints of pain. The plan is to continue the current goals and treatment plan, report progress to the occupational therapist, and schedule the next session.

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    of 1

    11/6/2023 12:00pm

    S: Pt arrived happy and ready to engage in her session.......................................................................


    O: Pt participated in a two-minute walk. Pt walked about 15 feet with a 2WW with mod one person
    assistance. Pt required minimal support on her lower back during the walk and when pt turned back
    around. During the walk right hand was guiding the Pt in the front, left hand was trailing behind. Pt was
    able to lead herself. Pt required mod assistance sitting back down into her
    chair..........................................................................................................................................................
    A: The Pt demonstrated progress including getting out of the chair with mod assistance. Pt successfully
    walked with a 2WW and turning herself back around. The Pt response was positive, wasn't complaining
    about any pain.....................................................................................................................
    P: Suggested to continue with the Pt original establish goals and plan. Report treatment progress to OT.
    Schedule the next session for November 6, 2023.................................................................................
    Isabella Williams PTA/OTA Student Durham college................................................................................
    Cosign by Therapist

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