Soap note.d

Soap noteName:
Course:
Tutor:
Date:
Soap Note
S: The client stated had an 18q deletion problem. Her condition affected many areas like feeding, personal hygiene and also toilet hygiene. Her parent stated that, “Sheila had issues in getting her shoes and socks off with no problems. She also has a problem with communication.” Her parent continued to state that, “Sheila also has a problem with her eating habit and also her personal hygiene. She is not able to do her clothing or manage it when toileting.”
O: The client performs occupational treatment (OT) to assess the daily routine of Sheila. The goals of this OT treatment were to achieve the following:
That Sheila will improve her communication skills with the help of an electronic communication device.
That Sheila will improve her grow her digital strength wise and by at least twenty-five percent on the bases of digital dynamometer measurements in a period of five months.
The activities which are to be done include placing loose change into a piggy bank and utilization of finger puppetsCITATION She07 p 47 l 1033 (Sherry Borcherding 47).
A: Sheila’s low tone, underdevelopment fingers and her impaired hands which do not actually respond to manipulation of tiny objects. Although problems are faced while regulating her emotions, some improvements are noted as her engagement with visual activities, verbal and physical cueing are improving. Sheila is expected to benefit from the OT treatmentCITATION She07 p 69 l 1033 (Sherry Borcherding 69).

P: Sheila will be attending an OT clinic for treatment and for some exercises which can be offered in sensory integration gym. she is also expected to undertake social skills in groups available in the OT clinic
Short-term plans

Sheila will continue with her OT services to for some weeks to improve fine motor skills.
Long-term plans

Sheila is expected to decrease her emotional outburst with activities transitions.
Works Cited
BIBLIOGRAPHY Sherry Borcherding, Marie J. Morreale. The OTA’s Guide to Writing SOAP Notes. SLACK Incorporated, 2007.