Make up a title
Question
please write a SOAP note for the case I choose. (Physical therapy)
the case is below:
This patient is an eighteen year old female who had anterior cruciate surgery today to her right knee. She will be going home today as soon as she demonstrates a safe transfer. She has complained of dizziness the last time the nurse tried to stand her up. Her blood pressure, she says, is a little low. The technique is for a long sit transfer with minimal assist of 1 to go from the bed to the chair. She will need vital signs taken before the transfer and during the transfer.
I attached a Rubric for this assignment so please check and write the SOAP note correctly.
Use as much medical abbreviations as possible..
SOAP Notes Rubric
Name
Criteria |
S |
N |
U |
Comments |
S 1. Correctly
categorizes information 2. Pt
comments are incorporated in the note 8 pt total |
|
|
|
|
O 1. Correctly
categorizes information 2. Note
is complete with enough information for other’s to be able to carry out
intervention( 8 pts) 12 pt total |
|
|
|
|
A 1. Correctly
categorizes information 2. Pt’s
response to session 3. Your
thoughts on the session 12 pt total |
|
|
|
|
P 1. Correctly
categorizes information 2. Plan
for next session? 8 pt total |
|
|
|
|
Feedback 1.
Incorporates feedback into assignment 4 pt total |
|
|
|
|
Medical Terminology and Abbreviation 1.Consistent use
of correct medical terminology and abbreviations 4 pt total |
|
|
|
|


Solution
SOAP for Case Study
Subjective data
The subjective data entails the
information the patient provides. In the case above, the patient complains of
dizziness upon ambulation which may indicate low blood pressure or orthostatic
hypotension. The patient also notes that their blood pressure is lower than
their baseline values.
Objective data
Objective data encompasses the
assessment data taken through inspection, palpation, percussion and
auscultation. Vital signs to include temperature, pulse rate, respirations and
blood pressure offer insights to the general well-being of the patient and any
deviations from normal physiology. The patient is unable to walk following the
surgery
Assessment
The patient requires time postoperatively to recover and regain their
limb function. From the assessment data, the patient has impaired physical
mobility that translates to self-care deficit. The dizziness puts the patient
at a risk of syncope and trauma following falls. Impaired skin integrity at the operation
site.
Plan
Close monitoring of the patient to minimize risk of trauma following
falls
Provide the patient with a walking frame to encourage early ambulation to
reduce complications and joint stiffness
Monitor vital signs which may provide indicators in case of change in the
status of the patient
Close monitoring of the patient’s blood pressure especially following
their complaints of dizziness to determine the etiology
Perform passive joint exercise followed by active exercises such as
physical therapy to preserve joint function
Avoid heavy physical exercises especially knee pivotal physical activities
until the full role of the knee is regained with complete Range of Movement
(ROM).




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