Soap Notes Flashcards
What does SMART stand for?
Significant. The goal has to make a difference in client’s life.
Measurable. Target aim. To know when client reached goal.
Achievable. Reasonable that the client could achieve goal in allotted time.
Related. Clear connection with client’s occupational needs.
Time-limited. STG/LTG has a designated chronological end point.
What does SOAP notes stand for?
Subjective. Relevant information client reports to the therapist
Objective. “Facts” Non-negotiable I.e., client was able to do 4/10 with 2 rest breaks. Therapist documents test, result of assessment this section has to be measurable, observable quantifiable.
Assessment. $ analyze and adjust [as indicated by… As evidenced by…] here you answer question so what ? Should end with statement justifying continued services.
Plan. Intervention plan outlined. Client achieves STGs new ones are stablished.
Note: relevance of discharge plan; time of discharge plan starts @ date of admission.
What does RUMBA stands for?
Relevant. Outcome must relate to something, how relevant is to the goal.
How long will it take to achieve the goal
Understandable. Anyone reading must know what it means.
Measurable. Has to be a way to know when goal has been met.
Behavioral. Describe behaviors.
Achievable. Realistic and must be do-able.
Definitions of level of assistance base on the Functional Independence Measure. FIM [levels of assistance in 7 point scale]
NO HELPER
- Complete independence (timely, safety)
- Modified independence. (Device)
HELPER MODIFIED DEPENDENCE
- Supervision. ( subject=100%)
- Minimal assistance (subject=75% or +)
- Moderate assistance (subject=50% or +)
HELPER COMPLETE DEPENDENCE
- Maximal assistance (subject=25% or +)
- Total assistance is not testable (subject less than 25%)
AREAS OF OCCUPATION.
Provide examples of ADLs
Bathing/showering Bowel/bladder management Dressing Eating Feeding Functional mobility Personal device care Personal hygiene/grooming Sexual activity Toilet hygiene
Provide examples of IADLs
Care of others Care pets Child rearing Communication management Community mobility Financial management Health management and maintenance Home establishment and management Meal preparation and cleanup Religious observance Safety procedures/emergency responses Shopping
Provide examples of rest and sleep
Rest
Sleep
Sleep preparation
Sleep participation
Examples of education
Formal education participation
Informal personal education needs or interests exploration
Informal personal education participation
Provide examples of work
Employment interests/pursuits Employment seeking/acquisition Job performance Retirement preparation/adjustment Volunteer exploration Volunteer participation
Play activities…
Play exploration
Play participation
Activities of leisure
Leisure exploration
Leisure participation
Social participation
Community
Family
Peer, friend
PERFORMANCE SKILLS
Example of Motor skills
Move
Physically interact with:
Tasks, objects, contexts, environments
Bend, reach, pace, coordinate, maintain balance, anticipate, adjust, manipulate.
Praxis examples:
Carry out…
Sequential motor acts as part of overall plan
Carry out learned activity…
Imitate a person, an object, sequence actions
Follow through on verbal command…
Spatial construction
Ocular
Oral
Organize temporal sequences w/in…
Spatial context
Sensory-perceptual skills…
Locate Identify Respond to Select Interpret Associate Organize Remember Visual, Auditory, Proprioceptive,Tactile, olfactory, gustatory, vestibular, position of the body, hear & locate sound, visually determine, locate by touch. Time appropriately Discern
