HSC 3243 Lecture Notes - Lecture 20: Cutting Board, Occupational Therapy, Soap Note
Document Summary
Writing the soap note: soap note format, based in the problem oriented medical record (pomr, client centered, focused on problems and progress, soap is an acronym, subjective, objective, assessment. Progress: also include inconsistencies, emotional components, changes, justify continued ot services. Pt. had no active movement of her dominant r. ue. She was able to ambulate into the kitchen with modified independence using a quad cane and to stand at the refrigerator to retrieve items needed, and at the sink to wash vegetables. She sat at the kitchen counter to assemble the sandwich. Client needs min assistance for stabilization of the package to remove tukey, position tomato on adapted cutting board, and use a sliding motion with the knife. Adaptive equipment (cutting board with nails and nonslip mat) was introduced and the client was instructed in its use. Client is able to use the equipment correctly and nodded to indicate understanding of the instructions given.
