SOAP Note
Name: Janis Melbourne
Dx: RCVA s/p 4 weeks
Age: 45
S: What about this one? This is my favorite. I thought you might need a spoon or a
knife? When asked what she was looking for in different drawers Janis replied There is
a lot of cute stuff in here.
O: Occupational Profile: Client is a 45 year old female who experienced a RCVA 4
weeks ago. Client has been married for 2 years and has a dog whom she likes to take
on walks. Together she and her husband have 4 kids from previous marriages. Her 15
year old son is the only one who lives with them, but will stay at his dads until she is
done with rehab. She was working full time as a paralegal and is currently on medical
leave. She hopes to return to work in the next few months. She likes to volunteer twice
a month and drives a SUV. Her husband works full time, he is currently using FMLA to
stay at home with her but must return to work in 3 weeks. Client will be left home alone
during the day at that time. Client has some active movement in her left UE but tends to
not use it in functional tasks. She has the following movement in her left UE: Shoulder
flexion: 45 degrees, Shoulder Abduction: 60 degrees, Elbow Flexion: approximately
ROM, no extension, Finger and Thumb flexion: full gross grasp, no extension
Client was seen for two different sessions for an extensive occupational therapy
evaluation to assess her occupational needs and ability to be left home alone after
having recently been discharged from inpatient rehabilitation. The Canadian
Occupational Performance Measure (COPM) was performed along with, 4 subtests of
the Performance Assessment of Self-Care Skills (PASS), and an occupational task was
observed.
The COPM is a standardized criterion-referenced interview that helps the client identify
occupational tasks and areas that need improvement. Client was asked to rate each
identified concern on a scale of 1-10 for both performance and satisfaction. One being
poor performance and not satisfied, and 10 being performs well and total satisfaction
with performance. The following were her results.
COPM chart
Occupational Performance Problems
Medication
Return To Work
Shower/Dress
Household (Bills &Clean)
Performance
8
3
7
7
Satisfaction
8
2
5
2
Time with Dog
1
26/5= 5.2
1
18/5=3.6
TOTAL
Her top priorities include: Spending time with dog, returning to work and performing
household task such as cleaning and paying bills. Her ability to stay home
independently will also be addressed since that is the reason for her referral.
The PASS is a criterion- referenced assessment that uses everyday tasks to observe
clients ability to complete them and perform correctly. There are 26 subtests. Client
performed 4 of the subtests that included: dressing, Shopping, Medication
Management, and Flashlight Repair. Each task was rated in 3 different areas on a scale
of 0-3. Independence (3= no help needed, 0 Total Assist), Safety ( 3= Safe Practices
Observed, 0= Severe risks to safety were seen, Adequacy ( 3= Acceptable
performance, standards met, 0= Unacceptable, progress unattainable.)
The following were the results:
Subtest
Independenc Safety
Adequacy
e
Dressing
2.7
2
1
Shopping
2.2
n/a
2
Medication
2
2
1
Management
Flashlight Repair
1.7
3
1
These results indicate that client was able to perform tasks with minimal cueing. Some
minor safety concerns were observed and she scored low in adequacy.
Observational Performance
Client was observed while making cheese and crackers. Client was able to propel self in
w/c with right leg to get crackers from the cupboard and cheese from the refrigerator.
Client required multiple verbal cues to remind her what she was supposed to be doing.
Client retrieved several knives from the drawer and needed a verbal prompt that only
one knife was needed. Client was able to efficiently cut slices of cheese using only one
hand but needed a prompt that she had cut enough cheese. She used her left hand to
stabilize the crackers while she opened them and took out a few to put on a plate. Client
did not use safe techniques when transferring the cheese to the plate, she used a knife
to poke the cheese. During the task client required 1 verbal prompt to scoot back in w/c.
Once when bending over to retrieve a toy for her dog, client lost balance and almost fell
out of her w/c but was able to quickly sit back and recover.
Environment Assessment
Client is 45 year old woman who lives at home with her husband and 15 year old son.
There are stairs in her home that lead to a basement but client just stays on the main
floor. Her kitchen is inaccessible for her w/c resulting in high counter tops. Client has a
two door refrigerator that she is able to open while sitting down. Her kitchen includes an
island but does have space around it for her w/c to fit. Client is able to navigate her w/c
in kitchen.
A: Client is happy, very engaging woman who likes to talk. She has an upbeat attitude
and is willing to do whatever is asked. Client identified areas of concern during the
COPM, but since her husband will be returning to work in 3 weeks it is important for
client to be able to be safe and independent when home alone. Therefore household
activities (e.g. cleaning, cooking), shower/dressing will be addressed first before
spending time with her dog, or returning to work. During the evaluation safety concerns
were seen due to client getting easily distracted and trying to do tasks too quickly. Once
cued to remind her what she was doing or to have her re-read instructions she was able
to fix her mistakes and get back on task. Clients left hemiparesis made it difficult for any
task that requires bilateral movement such as dressing, cooking etc Client is able to use
LUE but requires cues to use it. Client is an excellent candidate for skilled occupational
therapy she wants to become independent again and desires to return to work and will
therefore work hard to be successful.
P: Client will continue to receive skilled occupational therapy services 3 x/week for the
next 4 weeks. We will work on independent transfers to/from w/c to the toilet and bed.
We will work on dressing in preferred clothing required for work, and we will address
strategies she can use when cooking, shopping etc to stay focused and not miss a step.
LTG: In 3 weeks client will independently transfer to/from w/c to toilet.
STG: In 2 weeks client will transfer from to/from w/c to toilet with no more than 2 verbal
cues for safety.
STG: In 1 weeks client will transfer from to/from w/c to toilet with stand by assist.
LTG: In 4 weeks client will independently and safely prepare a complex hot meal.
STG: In 3 weeks client will prepare a simple hot meal with no more than 3 verbal cues
to observe safety precautions.
STG: In 2 weeks client will prepare a cold meal with no more than 2 verbal cues to
observe safety precautions.
Dawn Yearsley, OTS
