Chapter 08: Pulling it All Together
SOAP Note Activities
Now it is your turn to pull together everything you have learned thus far to create complete SOAP notes.
We will start the process by practicing on “paper patients” — you will read a narrative of a hypothetical patient treatment session and then create your SOAP note from the information given.
After we complete the four scenarios, we will then progress to writing our notes from videos of patient treatments. These video-based scenarios are from the International Clinical Educators database which we have access to through the Penn State Library system. The links and instructions to these videos are located in the Appendices section. You will need to be on-line to access them.
SOAP Note – Activity #1
Doc Ex 28: CREATE A SOAP NOTE: 1
You are working in a nursing / rehab hospital. Your patient arrives in the physical therapy gym via a wheelchair. He had RTHA that developed an infection and the prosthesis had to come out and a spacer was put it. You are seeing him in this rehab setting, with a goal of returning home with his wife within the next week.
He explains that the side of his hip was painful this morning; between 2-5/10. You ask for more information and learn that it is a 2/10 at rest and 4/10 with mobility. You propel the w/c to the parallel bars and moderately assist him to standing. He then ambulates the length of the bars two times with contact guard. You do need to reinforce to the patient that he is only permitted to touch his toe to the ground during gait or transfers. He sits and needs to rest because of pain and because he mentions how tired he is feeling.
You then propel the w/c the mat table. With minimal assistance, he transfers to the mat. He then performs: quad sets, ham sets and glut sets all with verbal instructions to correctly complete each exercise and to achieve full ROM): 3 sets of 8 reps.
His pulse rate before gait was 68 bpm; 92 bpm afterward. His BP: 120/80 before gait; 138/80 afterward.
He explains that he is still is very tired from his morning’s session. You transfer him back into his w/c with minimal assistance and allow him to return to his room to rest.
Please create your own SOAP note from the information above.
SOAP Note – Activity #2
Doc Ex 29: CREATE A SOAP NOTE: 2
Your patient is 2 weeks s/p left ACL reconstruction with a hamstring graft. The patient reports being able to walk with one crutch over the weekend for the first time. The treatment today consists of Stationary Bike x 8 mins for range of motion. No resistance used, only a rocking motion with the seat at height 15. Standing step flexion stretch was completed at a 14-inch step for 10 repetitions. Each rep was held for 10 seconds. Standing bilateral calf raises were completed; 20 repetitions x two sets. Patient next performed lateral weight shifting x 1 minute followed by SLRs in brace for 30 repetitions. Patient then completed heelslides, 2 sets of 10 repetitions. After ther exer, NMES to left V