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Physiotherapy SOAP notes for placement. Example 2
- Module
- Physiotherapy
- Institution
- Edinburgh Napier University (ENU)
SOAP notes example for Physiotherapy student on placement.
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Physiotherapy at TIME OF VISIT ((seen with name and role)S: Patient consented to assessment and treatment. History and charts reviewed. Pt is seemingly well
and keen for PT session.
O: Therapy handling RA ( number of risk assessment considered according to placement protocol)
NEWS: 0
pt. Lying in bed
Prosthetic limb on on arrival
Transfers:
Sit to stand to the WZF: requiring supervision of 1, pt retropulsive and requires multiple attempts to
stand to WZF.
Mobility: mob 20m with AX1, pt. required 1X seated rest due to pain in lower back
//ongoing pain in lower back
//step to gait pattern with reduced clearance of right lower limb
A: A: patient’s mobility continues to improve as he appears able to walk short distances and t/f on daily
basis with AX1. Back pain limiting patient to walk longer distance and be independent with WZF. Pt
requires ongoing rehab and assessment to determine if able to return to his baseline.
Problems:
1) Ongoing back pain
2)Pain in L heel
3) Assistance required with donning of prosthetic limb
4) Reduced transfer ability (requiring AX1)
5) Reduced mobility
6) Requires stairs assessment prior to discharge
Goal:
1) pt able to walk 30m with WZF in 1/7
2) pt able to complete bed transfer and chair transfer independently in 2/7
3) pt able to complete a stairs Ax in 1/52
Criteria for Discharge: Able to transfer and mobilize with the WZF and complete the stairs (not achieved)
P:
-PRN analgesia prior PT session if required
-mobility practice -increase mobility distance and reduce assistance.
-encourage independent donning of prosthetic leg
-Transfer practice
-Stair's assessment when appropriate
Name of student PT student
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