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An OT is working with a patient in the in-patient rehab department. The patient recently had a TBI after a motor vehicle accident and has become very agitated. When the OT presents the patient with a grooming activity of brushing his teeth he throws the tooth brush on the floor and states that he wants to be left alone. How should the OT best document the session in the “A” part of the SOAP note?
A) Patient became agitated and has difficulty following instructions
B) Patient appears to be agitated and threw the toothbrush on the floor
C) Patient stated “he wants to be left alone”
D) OT will continue to work on grooming activities with the patient

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Posted by (Questions: 108, Answers: 97)
Asked on February 13, 2017 4:02 pm
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Answer A) In the ”A” part of a SOAP note, the OT provide their professional assessment of the patient’s status. This is the OT’s professional opinion of the improvement or worsening of the patient’s ability to function. It is important to document whether the patient has been compliant with the treatment, whether the program is optimal and the factors contribute to progress or failure.

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Posted by (Questions: 108, Answers: 97)
Answered on February 16, 2017 2:09 pm
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A) Pt. became agitated and has difficulty following instructions

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Posted by (Questions: 3, Answers: 38)
Answered on February 14, 2017 4:59 pm
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