Question

From Documentation Book Worksheet 4-1

Translate each sentence written with abbreviations into full English phrases or sentences.

1. Pt. I BADLs.

2. Client reports ↓ pain R shoulder p HP.

3. Resident w/c ↔ EOB with SBA.

4. Client c/o pain in R index MCP joint p ~ 2 min PROM.

5. Client w/c → mat c sliding board max A x2.

6. Pt. O x 4.

7. Client has SOB p 30 reps of UE PRE.

8. Pt. has ↓ STM and OCD which limit IADLs.

9. Pt. min A AMB bed → toilet 2° ↓ balance.

10. Child’s FM WFL to don AFO I.

Answer 1

1.Pt.I BADLs:Patient is Independent in Basic Activities of Daily Living (BADLs). This is the basic daily activities that was performed to the patient with the help of nurses they can do independently.

2.Client reports that with decreased (pain in right(R) shoulder after hot pack(HP) treatment that is used or written in medical notes by doctors. Hot pack treatment used in the physical therapy clinics that is applied to the injured parts of human body that hot pack applied directly on the exposed area for pain relief treatment.

3.Resident is transferred from the wheel chair(w/c) to the Edge of Bed (EOB) and resident was returned($\leftrightarrow$) back to the wheelchair with the stand by assist used in medical notes .it is medical abbreviation that is used when the resident will not walk by his/her health conditions.

4.Client complain or case of pain(c/o) in the right (R) metacarpophalageal joint (MCP) after approximately 2minutes of the passive range of motion used in medical notes .These the case of pain at the metacarpophalageal joint that raises with in 2 minutes by the movement.

5.Client was transferred($\rightarrow$) from the wheel chair(w/c) on the mat using a sliding board maximum assistance of two people or persons(A*2) used in medical notes .Client was transferred from the wheel chair to mat with the help of two person by using the sliding board.

6.Patient(Pt) is alert and oriented to the person(who they are), place (where they are), time (when or what the date) and situation(why they are)(O*4). It refers for the assessment of the cognitive status of the patient.

7.Client had shortness of breath(SOB) after 30 repetitions doing or performing progressive resistance exercises (PRE). Shortness of breath seen by doing vigorous exercise by people it is common sign those who are performing exercises.It is commonly seen above 50 age people.

8.Patient(Pt) has decreased short term memory and Obsessive compulsive disorder (OCD) which limits the ability of to do instrumental activities of daily living (IADL). Persons who are suffering with OCD has a deficiency of non verbal and visual memory.
9.Patient(Pt) required minimal(min) assistance to ambulate from the bed (AMB) to toilet that is secondary(2) to decreased balance.If the patient not able to walk they need assistance to do their daily activities like from bed to toilet or for bath.

10.Child's fine motor(FM) skills are with in normal functional limit (WFL) to put on her/his ankle-foot orthosis (AFO). Ankle foot orthosis is device used to assist the mobility of patient.

This all abbreviations used in SOAP notes for easy understanding.