SOAP MID 2

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Author:
elementsninja
ID:
299756
Filename:
SOAP MID 2
Updated:
2015-04-02 14:23:09
Tags:
SOAP MID
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Description:
SOAP MID 2
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  1. WD/WN
    LTG
    UE
    PROM
    SCI
    • well developed, well nourished
    • long-term goal
    • upper extremity
    • passive range of motion
    • spinal cord injury
  2. ORIF
    PAM
    CGA
    BK
    PWB
    • open reduction, internal fixation
    • physical agent modality
    • contact guard assist
    • below knee
    • partial weight bearing
  3. W/C
    AAROM
    F
    UA
    FWB
    • wheelchair
    • active assisted range of motion
    • fair
    • urinalysis
    • full weight bearing
  4. OOB
    PRN
    Dx
    CPAP
    • out of bed
    • as needed
    • diagnosis
    • continuous positive airway pressure
  5. HOB
    WNL
    DOA
    RUGS
    MS
    • head of bed
    • within normal limits
    • dead on arrival, date of admission
    • resource utilization groups
    • multiple sclerosis
  6. NKDA
    DOB
    TBI
    CVA
    RA
    TKR
    • no known drug allergy
    • date of birth
    • Traumatic brain injury
    • cerebrovascular accident
    • RHEUMATIOD ARTHRITIS
    • TOTAL KNEE REPLACEMENT
  7. Client able to respond to verbal instructions and questions with correct response 3/3 times
    OBJECTIVE
  8. Client used walker to maneuver throughout kitchen with min verbal cues to place walker in appropriate position for reaching objects in kitchen.  Client was instructed in use of walker basket and wheeled cart to transport items
    OBJECTIVE
  9. Client’s ability to accurately demonstrate exercises and use of button hook indicates good rehab potential.  Client appears motivated and able to follow-through with home program.  Client’s ability to accurately demonstrate exercises and use of button hook indicates good rehab potential.  Client appears motivated and able to follow-through with home program
    ASSESSMENT
  10. Problems, progress and potential are elements of which section of the SOAP note?
    ASSESSMENT

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