SOAP NOTE EXERCISE-Prepаre аn аpprоpriate ASSESSMENT based оn Objective Infоrmation. (3 points: 1 point per sentence, 3 sentences required)COTA Treatment Session-Patient with General Weakness Subjective: Patient stated "I am so tired, can we skip therapy today?" with max verbal encouragement patient agreeable for OT session bedside only. Objective: Patient refused to complete bathing this am due to being tired. Upper body dressing completed sitting edge of bed with patient completing 40% of task due to decrease bilateral upper extremity strength. Patient completed stand pivot transfer from edge of bed to wheelchair with use of wheeled walker completing 75% of task. Lower body dressing completed wheelchair level with patient completing 50% of task and leaned side to side in wheelchair to don pants up over hips. Patient requested to use the restroom completing toilet transfer with use of grab bars completing 100% of transfer. Patient completed 25% of toileting task per pants up and down and self-cleaning. Patient left sitting in wheelchair at bedside with call light. Assessment: Plan: Patient will continue to benefit from Occupational therapy to increase functional independence with self cares and functional transfers. Patient to be seen 3 x week for 4 weeks.
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