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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? Marked as spam
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Private answer
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. Marked as spam
 Posted by admin (Questions: 104, Answers: 96) Answered on February 16, 2017 2:09 pm
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Private answer
A) Pt. became agitated and has difficulty following instructions Marked as spam
 Posted by WFORTI (Questions: 3, Answers: 38) Answered on February 14, 2017 4:59 pm
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