Fieldwork SOAP Note Revision

OLD OBJECTIVE

On 6/12/25, the client, a hemi post-stroke individual, was seen by OTA/S in the SNF rehab gym to address dynamic standing balance for LB dressing and transfers. The client completed STS from the bed to a w/c with a hemi-walker, CGA. The client was prompted to bring the R leg over the L to fix shoes and was able to lift the R leg (I). The client then performed STS transfer from the w/c with CGA. The first activity involved standing dynamic reaching with blocks scattered on the table surface. The second activity required functional reaching using an AE reacher to pick up scattered bean bags, with CGA provided as the client leaned forward to reach down. The activity was graded down by offering an easier-to-grip reacher and then graded up by moving the basket to promote different trunk movements, followed by further grading with weighted bean bags. The client required min v/c and min A to correct body positioning while sitting. In the third activity, the client completed simulated dressing using a theraband, with CGA to facilitate reaching down. Finally, the client performed STS with a walker to w/c, requiring tactile cues for

TEACHER FEEDBACK

• Justify levels of assist. Why was CGA needed? When giving lvls of A, always indicate why.

• ex. CGA given for safety dt decreased dynamic standing balance and festinating gait 2/2 old CVA, indicating fall risk

• What other surface did the pt xfer to? wc > ? Indicate this as multiple surface xfers are included in the goal.

• Why is this activity skilled and what was the focused of this activity?

  eg: Pt participated in dynamic reaching in standing c blocks scattered at tabletop to promote standing balance and act tolerance with emphasis on awareness with threshold of limitations to inc safety during dressing ADL.

• Include an area of A with your justification.

  eg: ...CGA provided as pt demos decreased trunk stability in anterior flexion when reaching towards the floor.

  This gives us the skills and performance areas that need attention and remediation.

• Why is this activity skilled and what was the focused of this activity?

  eg: Pt participated in dynamic reaching in standing c blocks scattered at tabletop to promote standing balance and act tolerance with emphasis on awareness with threshold of limitations to inc safety during dressing ADL.

On 6/12/25, the client, a hemi post-stroke individual, was seen by OTA/S in the SNF rehab gym to address dynamic standing balance for LB dressing and transfers. The client completed STS from the bed to a w/c with a hemi-walker, CGA. The client was prompted to bring the R leg over the L to fix shoes and was able to lift the R leg (I). The client then performed STS transfer from the w/c with CGA. The first activity involved standing dynamic reaching with blocks scattered on the table surface. The second activity required functional reaching using an AE reacher to pick up scattered bean bags, with CGA provided as the client leaned forward to reach down. The activity was graded down by offering an easier-to-grip reacher and then graded up by moving the basket to promote different trunk movements, followed by further grading with weighted bean bags. The client required min v/c and min A to correct body positioning while sitting. In the third activity, the client completed simulated dressing using a theraband, with CGA to facilitate reaching down. Finally, the client performed STS with a walker to w/c, requiring tactile cues for

TEACHER FEEDBACK

• Why was the activity downgraded?

  eg: ...downgraded by using easier grip reacher dt poor negotiability 2/2 decreased hand strength.

• Include indications why activity was upgraded. We love upgrades as it shows skill improvement. Notes should also include pt success.

  eg: ...activity upgraded to facilitate just right challenge by... as pt demos inc act tolerance and static trunk stability while seated unsupported in wc.

• Using your clinical reasoning, why is this happening?

  eg: Min v/c and A given to correct positioning while seated dt decreased trunk control and poor protective reactions 2/2 residual sided deficits.

OLD ASSESSMENT

The client demonstrated deficits in dynamic standing balance when performing ADLs such as dressing and transfers. Client has made progress in STS transfers /c AE hemi-walker and can lift up legs to fix shoes, but continued therapy is still nede to improve functional (I). The client practiced preparatory standing dynamic reaching with blocks to enhance balance, and the difficulty was gradually increased by using weighted bean bags to challenge trunk control. The purposeful functional reaching activity using an AE reacher and bean bags targeted the client’s ability to perform ADLs, such as picking up objects from the floor. The simulated dressing with Theraband was designed to mimic real-life tasks, helping to improve dressing techniques and overall trunk mobility. The client’s potential with continued therapy is positive, as they are responding well to graded interventions and have shown the ability to achieve milestones with min A & CGA A. The prognosis suggests that, with consistent therapy, the client will continue to improve

• What does this observation indicate, or why is this important information?

  eg: pt demos deficits in dynamic standing balance when performing ADLs i.e., dressing and xfers, indicating inc fall risk.

CGA Justification Missing

“Why was CGA needed? When giving lvls of A, always indicate why.”

• ✅ Fix it by adding: The reason why Contact Guard Assist (CGA) was required (e.g., “due to decreased trunk control during anterior flexion”).

Transfer Destination Not Specified

“What other surface did the pt xfer to? wc > ?”

• ✅ Fix it by adding: The transfer was from wheelchair to what? (e.g., w/c → mat table or w/c → bed, etc.).

Missing Purpose

Missing Purpose of Activity #1

“Why is this activity skilled and what was the focus of this activity?”

• ✅ Fix it by writing: What therapeutic purpose it served (e.g., “to promote standing balance and activity tolerance for LBD”).

4. Missing Purpose of Activity #2

“Why is this activity skilled and what was the focus?”

• ✅ Fix it by stating: the performance skills being addressed (e.g., “to promote trunk control and postural stability for safe floor retrieval”).

Justification for CGA Should Include Area of Assistance

“Include an area of A with your justification.”

• ✅ Fix it by specifying: what the CGA helped with (e.g., “CGA provided due to decreased trunk stability in anterior flexion”).

Why was it graded?

“Why was the activity downgraded?”

• ✅ Fix it by saying: e.g., “due to decreased hand strength or coordination.”

Why Was It Upgraded?

“Include indications why activity was upgraded.”

• ✅ Fix it by saying: e.g., “due to increased tolerance or trunk control.”

Why Was Verbal Cueing/Assistance Given During Sitting?

“Why is this happening?”

• ✅ Fix it by stating: the clinical reason (e.g., “due to poor protective reactions and residual deficits”).

Why Is the Simulated Dressing Skilled?

“Why is this activity skilled?”

• ✅ Fix it by explaining: the functional carryover (e.g., “to strengthen movement patterns for LBD independence”).

Assistance Justification Again

Why is A req here?”

• ✅ Fix it by repeating the same logic—always tie assistance to a clinical reason.

Unclear Transfer Destination

“Where to where? A > B”

• ✅ Fix it by writing clearly: “from walker → wheelchair” or “bed → walker.”

Assessment Sentence Needs Clinical Insight

“What does this observation indicate or why is this important info?”

• ✅ Fix it by explaining clinical relevance, e.g., “indicating fall risk.”

Misplaced Content in Assessment

“This info is not a clinical assessment… should be in the O.”

• ✅ Fix it by: Moving certain justifications for activity grading into the Objective section, not Assessment.