SOAP Note Activities
Now it is your turn to pull together everything you have learned thus far to create complete SOAP notes.
We will start the process by practicing on “paper patients” — you will read a narrative of a hypothetical patient treatment session and then create your SOAP note from the information given.
After we complete the four scenarios, we will then progress to writing our notes from videos of patient treatments. These video-based scenarios are from the International Clinical Educators database which we have access to through the Penn State Library system. The links and instructions to these videos are located in the Appendices section. You will need to be on-line to access them.
You are working in a nursing / rehab hospital. Your patient arrives in the physical therapy gym via a wheelchair. He had RTHA that developed an infection and the prosthesis had to come out and a spacer was put it. You are seeing him in this rehab setting, with a goal of returning home with his wife within the next week.
He explains that the side of his hip was painful this morning; between 2-5/10. You ask for more information and learn that it is a 2/10 at rest and 4/10 with mobility. You propel the w/c to the parallel bars and moderately assist him to standing. He then ambulates the length of the bars two times with contact guard. You do need to reinforce to the patient that he is only permitted to touch his toe to the ground during gait or transfers. He sits and needs to rest because of pain and because he mentions how tired he is feeling.
You then propel the w/c the mat table. With minimal assistance, he transfers to the mat. He then performs: quad sets, ham sets and glut sets all with verbal instructions to correctly complete each exercise and to achieve full ROM): 3 sets of 8 reps.
His pulse rate before gait was 68 bpm; 92 bpm afterward. His BP: 120/80 before gait; 138/80 afterward.
He explains that he is still is very tired from his morning’s session. You transfer him back into his w/c with minimal assistance and allow him to return to his room to rest.
Please create your own SOAP note from the information above.
Your patient is 2 weeks s/p left ACL reconstruction with a hamstring graft. The patient reports being able to walk with one crutch over the weekend for the first time. The treatment today consists of Stationary Bike x 8 mins for range of motion. No resistance used, only a rocking motion with the seat at height 15. Standing step flexion stretch was completed at a 14-inch step for 10 repetitions. Each rep was held for 10 seconds. Standing bilateral calf raises were completed; 20 repetitions x two sets. Patient next performed lateral weight shifting x 1 minute followed by SLRs in brace for 30 repetitions. Patient then completed heelslides, 2 sets of 10 repetitions. After ther exer, NMES to left VMO, 50pps, 10 sec on/off x 10 mins with quad sets. The patient had an excellent quad contraction with the stimulation and quad sets today. The patient’s left knee range of motion was 3-80 degrees by when performing ROM; 0 – 90 degrees when therapist performs the ROM. Patient ambulating with one crutch with some limitation in stance time on the LLE. However, that deviation does not occur until after 150’ of sustained ambulation. With verbal cues, the patient is able to improve his stance time on the LLE. The patient is being seen twice a week in therapy. Next treatment you want will begin transition away from use of the crutch for ambulation.
Your patient is s/p tibial fracture and is in a left, lower leg external fixator. The patient is NWB’g on the LLE. The patient arrives in the therapy department in a wheelchair and offers a pain rating of 6/10 for LLE. The patient does add that there is an intermittent shooting pain in the front of the lower leg that extends into the top of the left foot during mobility activities.
You transfer the patient to a mat table with minimal assistance including minimal assistance to lift the LLE onto the mat to lie supine. The patient then performs ankle pumps 20 times, glut sets 20 times, quad sets 20 times, hip abd/add 10 times, heel slides 10 times: all with just supervision. SLR and short arc quads require some manual cues for correct technique (each 10 times).
Next you have the patient come to a sitting position with minimal assistance with L LE. Using bilateral axillary crutches, the patient is able to move from sit to stand with CTG. The patient then ambulates 10 feet to the wheelchair with contact guard assistance (NWB’g LLE). The distance is limited due to fatigue.
After a rest, you resume gait training and the patient is now able to ambulate 25 feet before fatigue causes the patient to ask to sit down . You congratulate the patient for today’s performance as the patient was only able to ambulate 5 feet x 2 yesterday.
Lastly, you practice scaling an 8″ curb with the patient because the patient has one step to enter her home. For this activity, the patient requires moderate assistance as you notice a posterior LOB. This skill is practiced just once due to fatigue. At the end of the session the patient notes that the pain has decreased to a 3/10.
Your patient is s/p tear of right Achilles tendon. The doctor has cleared the patient to begin wearing a regular shoe (patient had been in a walking boot for the last 6 weeks). The patient was additionally upgraded to WBAT (patient had been PWB’g – and ambulated with bilateral axillary crutches).
You review the PT POC and read that the treatment is to include: ROM activities (active and passive) as well as progression to WBAT RLE 3x/week x 1 month. After discussion with your CI, you both decide the best way to begin the progression from PWB’g in a cast boot to WBAT in a regular shoe would be to begin with PWB RLE in the P-bars. This is completed with only occasional verbal cues (length of P-bars x 3. This is a distance of 30’). As there was no increase in pain, you progress to PWB’g with crutches: 30’ with supervision; verbal cues for weight shifting to right as well as for heel strike.
You then begin standing weight bearing and weight shifting activities – all with close supervision: Lateral weight shift 10 times (2 sets) in p-bars with LUE support. No increase in pain noted.
In sitting, the patient uses the BAPS board: 10 reps each direction x 2 sets. The Prostretch 5 x 10 second hold for dorsiflexion/plantar flexion and towel scrunches x 10 reps. You also perform PROM to the R ankle in all directions holding each for 15 seconds.
The session ends with a cold pack to right ankle x 15 minutes.
Patient did note a stretching sensation during some of the above activities, but pain did not increase. For your next session you want to add theraband ex’s for the R ankle as tolerated.