Complete Clinical Assignment

Description

ORIGINAL INSTRUCTIONS:

Assessment Plan Assignment

Below you will see a summary of two different 1 hour treatment sessions for the same patient as well as a section summarizing the patient’s information.Please write the Assessment portion of a SOAP note based on how the patient performs from treatment session 1 to treatment session 2. Please also write the Plan section of the SOAP note including at least 2 ideas for treatment. The ideas need to be appropriate for the level of this patient.

Patient Information:Dx: CVA c L hemi. Weakness noted t/o L UE and L LE. Pt does have active movement in her L arm, but having difficulty grasping and manipulating objects. Pt c 3- strength in her L quads and 2 in her L gluts. Her static supported standing balance is F/F+, however, her dynamic supported standing balance is P. She is using a LBQC for amb.

PMH: HTN, CAD, NIDDM, S/P THR in 2009

Home Information: One story home with 3 STE with no HRs

Social Information: Pt likes to play golf.

Treatment Session One: January 31, 2010 at 1:32 p.m.

Pt arrived to Rx session in a w/c. She was not feeling very well. She said she was feeling very tired; hadn’t slept well the night a. Pt noted to be very quiet t/o Rx session, and appeared sad. The Rx session began with PTA t/f pt ? mat with pt using her LBQC. PTA had to give mod.PA. PTA noticed that pt puts all of her weight through her R LE and pushes post.during sit ? stand. Once pt is on mat, PTA works c pt doing repeated sit ? stands focusing on proper technique. PTA then has pt step ? on 4” step c R LE and reach ? and ? for bean bags c L UE, and toss into container. Pt needed to rest after about 10 bean bags for each of attempts totaling 4 attempts because of fatigue and SOB. O2 sat was89% after 1st attempt and noted to be 92% within 1 minute of sitting. PTA completed gt. training having pt use her LBQC. PTA had to give mod. –max. PA. Ptamb 25’, was unable to advance her L LE I, consistently looked down and hyperextension of her L knee was noted 75% of the time. 1 significant LOB noted when pt’s family arrived and pt turned her head to the L. After gt.training, PTA took pt back to her room.

Second Treatment Session: February 1, 2010 at 2:40 p.m. Pt arrived to Rx session in a w/c feeling better this date. Stated she slept much better last pm. The Rx session began c PTA t/f pt ? mat using LBQC. PTA had to give mod PA. PTA noted pt to have some post. pushing and pt putting more weight thru L LE during

sit?stand. PTA continued to have pt. practice sit ? stands at varying heights. PTA also had pt put R LE on 4” step and throw ball against a wall at various targets. Pt noted to be SOB with activity, taking frequent rest breaks. O2 sat 93%. PTA ended Rx c gt. training using LBQC. Pt having difficulty remembering what foot to move first. Pt looking down less with VC and TC from PTA. Pt starting to advance L LE on her own, however, PTA still needing to clear her L foot. Pt amb 30’ c mod PA – max PA from PTA, and pt able to control knee better. Pt not sad during any of the Rx session. P Rx was done, PTA took pt back to room.

Grid View

	Excellent	Good	Fair	Poor
Main Posting	45 (45%) – 50 (50%) Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	40 (40%) – 44 (44%) Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	35 (35%) – 39 (39%) Responds to some of the discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.	0 (0%) – 34 (34%) Does not respond to the discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness	10 (10%) – 10 (10%) Posts main post by day 3.	0 (0%) – 0 (0%)	0 (0%) – 0 (0%)	0 (0%) – 0 (0%) Does not post by day 3.
First Response	17 (17%) – 18 (18%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	15 (15%) – 16 (16%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	13 (13%) – 14 (14%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 12 (12%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response	16 (16%) – 17 (17%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	14 (14%) – 15 (15%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	12 (12%) – 13 (13%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 11 (11%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation	5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days.	0 (0%) – 0 (0%)	0 (0%) – 0 (0%)	0 (0%) – 0 (0%) Does not meet requirements for participation by posting on 3 different days.
Total Points: 100