Question

For this SOAP note critique assignment, you are to read and rewrite the SOAP note, making corrections and changes and integrating SOAP note documentation rules from your text. This SOAP note has some errors, is missing important elements, has some elements in the wrong place and has sentences that need to be rephrase d using appropriate medical terminology. The A' part of the note should highlight a reason for some of the elements of the .O'-what is your assessment of how the client is progressing (or not), or what some concerns might be and why. Use abbreviations and medical terminology in this SOAP note. If the symbols are hard to put in, it is ok to spell them out or abbreviate Here is the SOAP note to be critiqued- S: Client has back pain. O: Upon arrival, client was sitting in wheelchair, in his hospital pajamas and robe, looking at the TV in his room. He started talking to therapist several times, complaining of back pain and stating he felt depressed. He frequently looked at TV while talking to therapist. Client was asked to get ready to get dressed for the day. Client completed upper and lower body dressing from sitting position with a little bit of help. Upper extremity exercises reviewed with therapist and completed. He used both hands together during exercises and lifted arms together approximately 30 times while breathing in and out. A. Client is demonstrating improvement in dressing abilities from moderate to minimal assist this week. P. Continue plan of care.

Answer 1

SOAP note is information about the patient, which is written or presented in a specific order . A SOAP note consists of four sections including subjective, objective, assessment and plan

S( subjective ) includes subjective data - chief complaints , history of present illness , and medical history .

O ( objective ) includes objective data - vital signs , physical examination and investigation

A( assessment) - assess the patient for sign and symptoms

P( plan ) - implementation and continuation of plan

In the above SOAP note :-

S - patient complaints of backache.

O- The patient was having pain in his back and it was evident by the way he was describing it . He was confused and depressed . He was not able to put his dress himself ,needed support . While doing exercise he used both hands together and lifted arms approximately 30 times while breathing in and out .

A - On assessment , there was improvement in doing activity of daily living as he needed minimum assistance this week.

P- continue plan of care