Review: Spelling Errors
Pnumonia
What is pneumonia?
”I enjoyed the Major Leaguse Baseball playoff games over the weekend”.
What is an example of inappropriate content of a SOAP note?
The two questions to ask yourself when you are writing the ”O” section of your SOAP note
What are “What did the patient do?” and “How did the patient do?”?
The three P’s that will help you write your “A” section
What are problems, progress and potential?
CIMT
What is Constraint-Induced Movement Therapy?
Independant
What is independent?
The patient stated that transferring from her wheelchair to the raised toilet seat is very challenging.
What is an example of an appropriate “S” section note?
Level of assistance required to perform a task
What is information that belongs in the “O” section of a SOAP note?
The original intention of the “A” section of a SOAP note
What is a doctor’s diagnosis?
w/c<->toilet
What is “from wheelchair to toilet, toilet back to wheelchair”?
Urinary track
What is urinary tract?
What is an example of an inappropriate “S” section note?
The patient completed a one-step microwave meal preparation activity with one verbal cue.
What is an example of an appropriate “O” section of a SOAP note?
The client’s progress, functional limitations, pertinent issues, and expected gains from rehabilitation
What are topics that are appraised by the OT practitioner in the “A” section?
BSC
What is bedside commode?
Boutinniere deformity
What is boutonniere deformity?
The patient is exhibiting poor impulse control, as she abused alcohol after six months of sobriety.
What is an example of an incorrect “S” section note?
Interpreting information collected during the therapy session
What is information that does not belong in the “O” section?
A recommended sentence stem to end the “A” section of the SOAP note
What is “The client would benefit from…”?
SPC
What is Single-Point Cane?
Homonomous hemianopsia
What is homonymous hemianopsia?
The patient participated in 2# pulley exercises, 2 sets of 10 repetitions per set, without experiencing shortness of breath.
What is an example of an inappropriate “S” section note?
“Patient required close supervision for safe handling of hot foods when cooking” illustrates this principle of documenting assist levels.
What is “Be specific about assist levels”?
What is “Ability to engage in occupation”?
TED hose
What is thromboembolic disease hose?