PTA Therapeutic Skills II - 3303

Lab Skill Assessment #2 - Clinical Documentation - SOAP Note

Patient Name: Nadeen Cole Date: Dec. 18/17 HCN:123456789 DC

Subjective
Pt attended her 3 third treatment session with husband. Pt treatment goal is to improve the quality of
her gait cycle. Pt reports that she was feeling tired today and pain level is 4-10. Pt reports that she has no
contra-indications for FES and has intact skin and sensation in lower right leg. Pt gave verbal consent to
treatment after being reviewed the risk and benefits of treatment. ____________________________
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Objective
Pt skin was cleaned and examined before placing adhesive electrodes are placed on lower right leg on
TA. Stimulation parameters are 2 secs ramps up/down, 200us, 50hz, 5 secs ON, 25 secs OFF. Pt turned up
the intensity up to where it was comfortable level for her, which was 27. PTA attached self-manual switch
on FES for pt to switch ON and OFF during the gait activities. Pt sat on edge of plinth practicing using the
switch and getting use to the machine intensity for 2 cycles. Pt then stands ups to work on gait activity,
toe off to mid stance lift. PTA makes sure pt presses the switch when she lifts her foot off the ground
(ON) and pressing it (OFF) when bring it back down to starting position. Pt hand is supported on a table
beside her and PTA is standing be hide, watching pt posture, PTA used verbal cuing to keep pt head
looking up. Pt did 2 sets, 10 reps, with 10 secs breaks between each rep. Pt reported feeling fatigue half
way through, PTA toke a longer break. PTA closed session after the two sets leaving pt in waiting room
with husband. ____________________________________________________________________
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Analysis
Pt tolerated treatment well, pt seemed less fatigue than last sessions. Pt pain scale after
treatment was 3-10. _____________________________________________________________
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PTII 3303
 PTA Therapeutic Skills II - 3303
Lab Skill Assessment #2 - Clinical Documentation - SOAP Note

Plan
Report back to PT on treatment session and recommend progressing skill to add full swing in gait cycle,
due to patients increase ability of skill during treatment. Next session is December 21, 2017. _________
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Name of PTA
Amanda Wilkes (PTA Durham College student)

PTII 3303