Appendix G. Note Writing Exercise

1. Rewrite the following SOAP note in acceptable content format as a SOAP note.

2. Rewrite the following SOAP note in a narrative format with appropriate content and categorize the information.

NOTE # 1:

S: Fixed the lawnmower this weekend

O: Seen in dept. for cont with cybex protocol to BLE's 2 cycles r, 1 cycle L. Followed by balance beam, kicking ball, unilateral stance 15 sec. L unable to maintain L. Side <> side stepping. Side <> side gallop. Fast walking length of speech hall and back 196 in 45 sec 1st trial, 43 in 2nd, 36 in 3rd with encouragement. Kneeling-1/2 kneeling on mat 2 sets 10 reps. Amb 60′ with 8 hyperextensions 1st time, 4 2nd, 8 3rd.

A: Tol Rx well, fatigued with ex.

P: Continue

Note # 2:

S: Good spirits

O: Gait + advanced gait + balance techniques - instruction + practice.

A: Demonstrating good gait and balance with some proprioceptive L/E deficit + thus would advise to contact guard stand-by assistance for safety at present.

P: Continue as above

1. Write a chart entry for a patient that did not come to therapy today and did not call to cancel.

2. A patient is brought to PT but refuses to do anything and is disrupting others.