Brittany Norton

Soap notes
H.A.
S- pt. stated 0 pain before and after session.
O- pt. ambulated with single point cane with CGA approx. 50 ft. Tested cognition
with MOCA test, scored a 9/30; 26/30 is considered normal functioning. Red
theraband exercises completed 15x each of UEs: horizontal abduction/ adduction,
IR/ ER, elbow flexion/ extension, and rows. Completed 2# weight 15X sup/ pro, wrist
flex/ extend. And bicep curls. Needed verbal instructions for proper technique.
Required no breaks during exercises.
A- pt. shows decreased cognition as evidenced by score on MOCA test.
Demonstrates strength in upper extremities with use of 2# weight and use of red
theraband. Demonstrates good endurance as shown by no breaks required during
exercise.
P- Assess with ACL for further cognition testing. Recommend drivers test be
performed. Increase exercises to standing position to test balance and to increase
endurance. Collaborate with unit coordinator and direct of nurses for safest location
for d/c and recommend oral motor exercises to address excessive drooling as well
as providing a steadier chair to decrease fall risk.

Radial fracture
S- Pt reported 0 pain before, during, and after TX. Pt reported she continues to wear
her brace during the day and night.
O- pt. completed 6 pack exercises of right UE 10x each. 15lb hand gripper 25X reps
2X. Completed 1# hand weights of right UE: sup/ pro, wrist flex/ extend, and radial
and ulnar deviation. Completed AAROM on R UE: pro/sup, wrist flex/extend, and
ulnar/ radial deviation. Educated on HEP and provided handouts to complete of 10x
reps 1-2x a day or as tolerated.
A- pt. shows tightness in R hand and forearm as evidenced by AAROM stretching.
She is able to complete all exercises and demonstrates increase of strength and
endurance as evidenced by no pain or breaks during exercises.
P- Continue with established plan of care. Progress strengthening as tolerated.
Grade HEP as tolerated.

L.J.
S- Pt reported he is afraid to use pivot disk due to chance of falling. Pt reported no
pain before, during or after TX session.
O- Pt completed transfer w/ pivot disk assist of 2 from w/c to chair w/ MIA-MOA.
Completed transfer w/ pivot disk assist of 2 from chair to w/c w/ MOA- MAA.
Completed theraband exercises with red theraband 15x each on UEs: horizontal
abduction/ adduction, IR/ ER, elbow flexion, extension, rows, and diaganols.
Completed wrist strengthening exercises with 2# weight 15x sup/ pro, wrist
flex/extend and bicep curls. Complete standing with use MOA-MAA assist of 2 and
handrails for approx. 1 minute and 1 minute and a half with CGA of 2 to maintain
stand and verbal instruction for repositioning. Propelled w/c approx. 60ft w/ bilateral
UEs with 2X breaks and verbal instruction for proper technique to propel self
forward.
A- pt. demonstrates difficulty with pivot transfer and standing for longer periods of
time. Shows decrease of endurance as evidenced by low timed stands. Shows
strength in UEs and increased endurance as evidenced by repetitions of exercises
and requiring no breaks.
P- Continue with established plan of care. Progress strengthening as tolerated and
trial PAL transfer to see if it would be appropriate to d/c use of hoyer lift.