NURS 6501-LAB Assignment on SOAP NOTE About Patient Named Katie Wild-2023 5 Star Rated

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Assume that you have completed a treatment session with your patient, Katie Wild, and now you need to document this treatment session in her chart, using the SOAP note format. Refer to your readings a... nd presentations to make sure you clearly understand what information goes into each section. Katie Wild is a 73-year-old recovering from a total hip replacement. Katie demonstrates decreased lower extremity strength and endurance. She is unable to independently maintain her balance while standing to dress herself and fatigues easily. Treatment today included a morning activities of daily living (ADLs) session of grooming and dressing to observe and assist Katie and then to determine further ADL intervention as needed. Katie was seen by the OTA in her bedroom of the traditional care facility. Per the OTR’s evaluation, the plan of care includes that Katie will be seen 5 days a week for up to 60 minutes each day, for the next 2 weeks. Also per the evaluation plan, the following OT interventions will be implemented to achieve Katie’s goal of returning home independently and safely: skilled ADL training, use of therapeutic activities, strengthening and endurance therapeutic exercises. During treatment, you said “hi” and explained your reason for visiting with Katie Wild that morning. She said, “Oh goodness. I’m not sure I’m up for that sort of thing this morning.” You provided encouraging words, and when you had verbal agreement, you pushed her in her wheelchair to the bathroom sink. Katie performed her morning grooming and hygiene activities while seated at the bathroom sink with minimal assistance. You then pushed her wheelchair back into her bedroom area and asked her about the type of clothing that she wanted to wear that day. She told you that she wanted to wear her purple top with yellow sweater and black slacks. After you ensured that the wheelchair’s wheels were locked, you then suggested that she dress while seated in the wheelchair. She agreed. You find that Katie can dress her upper body, including donning her top and sweater. She can do this with you simply handing her clothing to her, in essence setting up this task for her. You find that she needs moderate assistance with maintaining her balance and needs the maximum amount of assistance to maintain her standing posture. She cannot stand for more than a few seconds without using the wheelchair for support. [Show More]

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