Soap Note

Pt. is an 83yo female admitted to hospital 10 days ago with dx of Bronchial Pneumonia. Admitted to SNF 2 days ago with balance and strength deficits. Pt. lives alone in a first floor apartment with 2 steps to enter with bilateral rails, and was relatively healthy prior to hospital stay. Pt. still drives and has a daughter who lives in the area. S. Pt. states ”I feel pretty good but am unsteady when I sit up in bed and try to walk” O.

Pt. seen for 30 min tx on this date w/ focus on static and dynamic balance training.

Pt. required CGA for sit to stand from w/c level. Pt. tolerating static standing for 5 minutes with SBA. Dynamic standing balance included weight shifting while reaching for cones, and balloon tapping and bean bag tossing, requiring Min A for standing safety for 2 minutes. Pt. also participated in lunges x10 at walker level, and resistive exercises in standing using red theraband 10 reps x2sets.

Pt. educated on breathing techniques and required moderate rest breaks. POX >96% on room air during PT session.

A. Pt. making steady progress with standing balance, with decrease tactile and verbal cues and increased standing tolerance and safety. Pt. able to compensate for loss of balance, by using Wwalker and a wide base of support. Pt. demo good understanding of energy conservation & breathing techniques, with decreased Shortness of breath during functional tasks. P. Advance to gait training next PT session. Increase standing tolerance and resistance during standing balance training per POC as tolerated.

Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more