SOAP NOTE

Student’s Name
Instructor’s Name
Course
Date
SOAP Note
S: The client stated, “I did not complete an art painting today in the morning. I felt pain in my wrist and forearm.” She also stated “I managed to button my blouse but felt slight pain on my shoulder. However, the pain was less when I combed my hair.”
O: Client took part in an Occupational Therapy (OT) session by engaging in activities of daily living (ADLs) such as buttoning her blouse, combing her hair, and painting an art piece. The client demonstrated an ability to increase ROM by using a comb with a long handle when combing her hair. However, the client’s muscle strength in RUE was not fully strengthened and hence, she needed an assistive device to complete ADL tasks including drawing and buttoning her blouse. She sat on a chair while buttoning and was able to use button hooks. She was also able to stand in the mirror for 8 minutes while combing.
A: Decreased ROM in RUE limit’s the client’s ability to perform certain ADLs. However, there is strengthening of muscles in the right arm due to use of assistive devices which reduces the strain of the RUE. The client should continue with active range of motion (AROM) exercises on the right shoulder to improve the ability to complete daily tasks. Most importantly, the client should continue using the assistive devices to ensure exercises are done within normal limits (WNL) to avoid injury on the RUE.
P: The client should continue with the current exercises for one week. Thereafter, she will be introduced in more rigorous PROM exercises to strengthen her muscles.

At the same time, she will be given endurance tasks of standing for at least 10 minutes daily to help in developing her balance.