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Week 3 Documentation: SOAP notes and evaluations Terms in this set (27) What does "S" stand for in a SOAP note? Subjective What is written in the subjective -Clients report of limitations, concerns, problems -Summarize what the client says7,80 €
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Week 3 Documentation: SOAP notes and evaluations Terms in this set (27) What does "S" stand for in a SOAP note? Subjective What is written in the subjective -Clients report of limitations, concerns, problems -Summarize what the client says
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Week 3 Documentation: SOAP notes and evaluations
Terms in this set (27)
What does "S" stand for in a SOAP note? Subjective
What is written in the subjective -Clients report of limitations, concerns, problems
-Summarize what the client says that is relavent to tx
-Use conversa...
Week 3 Documentation: SOAP notes and evaluations
Jeremiah
Terms in this set (27)
What does "S" stand for in a SOAP note? Subjective
-Clients report of limitations, concerns, problems
-Summarize what the client says that is relavent to tx
-Use conversation to build occupational profile
What is written in the subjective -If patient is non-verbal, may need to provide information that was provided by family,
caregivers or other professions
-EX. Client reports that her shoulder feels better after application of kinesiotape to
reduce subluxation
-Not using communication like effectively
Common errors when writing subjective -Not writing concise, coherent statements
-do not repeat the client's medical history
What does the "O" stand for in a SOAP note? Objective
-begin with a statement about the length, setting, and purpose of the tx session
-next, provide a brief overview of the key deficits that are affecting the client's
performance
What is written in an objective?
-follow the opening statement with a summary of what you observed; how did the
client present
-be professional, concise and specific
The formula is: Patient participated in a ___ _- minutes OT session in (what setting) for
(intervention) for (what occupational gain
Step 1 of writing an objective - EX. Patient participated in a 30-minute OT session in an outpatient clinic for skilled
instruction in joint protection and energy conservation to increase safety during ADLs
tasks.
-paint a picture
-one or two sentences to describe key deficits (PRESENTATION SENTENCE)
Step 2 of writing an objective
- EX. Client seated in w/c and presents with dense hemiparesis for (L) UE and (L) LE,
edema of (L) hand, and severe (L) neglect.
Week 3 Documentation: SOAP notes and evaluations
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