Ashley Thayn

November 2, 2018
University of Utah
Division of Occupational Therapy

SOAP #4

S: “I have a lot more movement in my fingers.” The client reported in regard to his neurectomy
surgery for his fingers.

O: The client reported completing four mirror therapy sessions of 30-45 minutes each over the
last two weeks for his HEP. Practiced finger extension and abduction exercises with resistance.
Client stated a preference for exercises and typing tests over IADL related to hand function.
Educated in purpose and importance of ………..Client agreed with information and was willing to
participate in IADL. Completed functional tasks that required repetitive finger flexion and
extension; thumb adduction and abduction, and pincer grasp both seated and standing. Client
dropped items twice during pincer grasp tasks and reported an increase in dropping items
when he wasn’t looking at his L hand. Required mod VC to engage his LUE in Bilateral UE
Training tasks. The client was instructed to practice finger abduction and extension exercises for
homework.

A: The client was willing to participate in therapy tasks and appeared pleased with the
outcome. Displays abnormal tone, muscle weakness, proprioceptive problems and limited
motor control limit his LUE function when performing functional tasks requiring finger flexion,
extension; and finger and thumb adduction, and abduction. Demonstrated decreased tone and
increased finger extension, adduction and abduction in his L hand after his neurectomy surgery
last week, 10/26/2018. Shortened soft tissue limit wrist supination and shoulder PROM. High
tone, minimal proprioception, and absent light touch result in hand dragging in functional tasks.
One goal has been met; two goals were discontinued, and two new goals were made

P: It is recommended that the client be seen for skilled OT services for 4 more sessions to
address LUE motor control and sensory function to improve his ability to engage in meaningful
occupations. Next session, we will address completed homework, LUE motor training, and
adding in more L hand letters when typing.

Goals

LTG 1: By discharge, the client will independently don socks, shoes, and Saebo brace while
incorporating his LUE using compensatory strategies.

STG 1: In 4 sessions, the client will be able to don L shoe over heel while incorporating his LUE
using compensatory strategies with min A.
STG 2: In 6 sessions, the client will able to fasten shoelaces using compensatory strategies with
mod I. GOAL MET 10/19/2018

LTG 2: By discharge, the client will increase typing speed by 5 wpm while incorporating LUE
using compensatory strategies.

STG 1: In 5 sessions, the client will use the shift key with L hand and min A, with less than 5
errors per sentence using compensatory strategies. Goal discontinued

New Goal STG 1: In 5 sessions, the client will use the shift key with L hand and min VC, with less
than 5 errors per sentence using compensatory strategies.

STG 2: In 7 sessions, the client will report improved satisfaction with typing performance on
weekly calendar while incorporating use of LUE with mod I. Goal discontinued

New Goal STG 2: In 7 sessions, the client will type 4 new letters with L hand with mod I.

Name: Ashley Thayn, OTS

Date: November 2, 2018