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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
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Criteria |
S |
N |
U |
Comments |
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S 1. Correctly categorizes information 2. Pt comments are incorporated in the note 8 pt total
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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 |
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A 1. Correctly categorizes information 2. Pt’s response to session 3. Your thoughts on the session
12 pt total |
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P 1. Correctly categorizes information 2. Plan for next session?
8 pt total |
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Feedback 1. Incorporates feedback into assignment 4 pt total |
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Medical Terminology and Abbreviation
1.Consistent use of correct medical terminology and abbreviations
4 pt total |
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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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