Physical Medicine and Rehab SOAP Note Sample Report #1
SUBJECTIVE: The patient states that his weekend went well. In particular, he states that his therapeutic pass/community reentry pass, though trying, was quite an eye-opening experience. He states that the experience was good for him.
OBJECTIVE: Temperature 99.0 degrees, pulse 88, respirations 20, and blood pressure 122/58. The head and neck examination was unremarkable. A Miami J collar was worn. The patient states he is not prepared to wear a soft cervical collar because it is not fitting well. He is waiting for a Philadelphia collar. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft, nontender, with active bowel sounds. There was no guarding or rebound tenderness. Thigh-high Ace wraps and TED hose were in place. The patient is wearing Stryker boots to pad his heels.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. A therapeutic pass yesterday was quite instructive for him. A team conference will be held tomorrow to review his functional goals and progress. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with soft cervical collar, though the patient continues to use a Miami J collar. Awaiting the Philadelphia collar.
3. Pain: Very little, if any, complaints except for occasional shoulder discomfort. Continue myofascial technique to the tight muscle groups in the upper trapezius muscles. Continue pain medications as written.
4. Bowel/bladder management: We will discuss this further during team conference. Working towards a regulated program. The patient and his family are involved with this.
5. Elevated temperature: Continues to fluctuate though a general trend of improvement is noted. The patient continues to receive ciprofloxacin for a urinary tract infection.
6. Left common femoral deep venous thrombosis: The INR today was 1.8. We will continue the Coumadin 7.5 mg daily and recheck the INR tomorrow. We hope to see a pattern and adjust the Coumadin accordingly.
7. Stage III sacral decubitus ulcer: Continues to heal with the electrical stimulation and nutritional supplements. We will evaluate this further during skin rounds tomorrow. We will likely continue the current plan of care.
Physical Medicine and Rehab SOAP Note Sample Report #2
SUBJECTIVE: The patient is without complaints today. However, he would nod off at times during the bedside evaluation. His father was at the bedside as well.
OBJECTIVE: Temperature 98.2, pulse 86, respirations 18, and blood pressure 92/52. Intermittent catheterization volume recorded, so far today, was 180 mL. The patient had a bowel movement earlier today. Head and neck examination showed the patient closing his eyes and nearly falling asleep one occasion. However, pupils are equal, round, and reactive to light. A Miami J collar was in place. Heart and lung examinations were within normal limits, except for a paradoxical pattern of respiration. The abdomen was soft and nontender with active bowel sounds. An abdominal binder was worn. The sacral dressing was intact. There was no lower extremity edema.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient is participating fully with encouragement in therapies. Discussions about spinal cord injury have been started. Continue comprehensive inpatient rehabilitation evaluation and treatment. Continue the prednisone taper.
2. Spine stability: Stable with Miami J collar. Continue present management.
3. Orthopedic: Surgical wounds are healing well. Continue spine precautions. The patient is scheduled for orthopedic followup next week.
4. Pain: Under good control. Perhaps, the patient may be able to be weaned from some of the medications as he is easily falling asleep. However, this could also be tiredness because of his decreased endurance.
5. Stage III sacral decubitus ulcer: Stable. The patient’s father again asked whether he could have a KinAir bed. He was told that the AccuMax overlay is appropriate for the patient and that his skin is healing. Continue wound care as written.
6. Pulmonary: Stable. Continue to work on improving the pulmonary status and diaphragm strength.
7. Neuropathic pain in the lower extremities: Reported more so in the left foot. The patient would like to hold off on adding Elavil to his treatment plan at this time. He will continue to use the Neurontin. The patient is aware that the Elavil will not interfere with the healing process.
Physical Medicine and Rehab SOAP Note Sample Report #3
SUBJECTIVE: The patient is without complaints. She states she was able to use the BiPAP overnight.
OBJECTIVE: Temperature 97.0 degrees, pulse 69, respirations 20, and blood pressure 113/48. The head and neck examination was unremarkable. The patient has a BiPAP machine at the bedside. A PICC line was noted in the right arm. A left exotropia was noted with dysconjugate gaze. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. There was a urostomy site as well as a colostomy site on the abdomen. There was also a PEG tube site. Knee-high TED hose was worn.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. She is showing fairly good endurance to be able to perform these activities. Continue comprehensive inpatient rehabilitation.
2. Hypertension: Good control. Continue present management. We may need to decrease some of the medications.
3. Lymphoma: Stable and followed by Dr. John Doe.
4. Depression: Slightly upbeat. Continue supportive therapy and medications as needed.
5. Bowel/bladder management: Manage with urostomy and colostomy. We will work towards a regulated program as well as teaching the family how to perform ostomy care.
