> ae SOAP Note 2: Evaluation and Intervention Report Grading Rubric (25 points) due 2/17; 2/19) (1) Appropriate and useful history! demographic information (S:_1_ (1) statement of client's family's narrative stance (©): 75 @) Evaluation overview includes cecupatiial profile and observation of occipational performance and any assessments Performed and informs the assessment procese BASIS) Assessments ae clearly and accurately interpreted (A) and displayed (@ 2.256) Supports and barriers are concisely summarized (includes context and activity demands) @}.2.5(8) Goal objectives (SMART formatare appropriate and feasible within timefiame (adress frequency duration} speifc recommendations for what you wll address are given 2 @ Diseuss proces of sting goals and plans wth lest ed " accurate Mona ime, butknows how tousehis 5. use the reminders application about 50% of the ions successfully on his own. Client met his goal touse $0 'y emo have Gorn te ¢s fovsina from our [ane Roe privtde 2 Caco, gt ou."D Gor reach of Uf calendar and notes appli schedule. Client has not met his goal of using his phone to complete his dacompensatory strategies with min VC to pay il because his home office stl to distracting fr him to wor there, He son tract mee this goal once ivan his wife decide onthe best way to organize the ofce for cents neds Client made listo goals to work on st home including paying ils, organizing fc space, sing phone consistently and picking atime for him to regularly pay bills By the end of the therapy session, lent was able totalkand doa taskat the same ime with ‘mod indirect verbal cues to keep attention to task. Client completed an end of therapy assessment to assess his satisfaction with therapy. Client required 2 breaks and could not fish the survey due to an odaly worded question He could not Figure ‘out what the question was asking and couldnt continue the survey because it became overwhelming. Client asked fr the breaks. [A Client made good progress over the 8 sessions. He hs the skills to complete his goals andis aware that in order to pay his bills, he needs to figure outa way to make the environment ess distracting and overwhelming to him, Client also knows that using his phone for reminders and notes can bet his advantage for keeping “organized and to asist with his therapy reminders. lietis aware of his abilities and his limitations and does well t adjusting his environment P: Discontinue OT service fom Life Skils Clinic 4/12/18. Client is discharged home, Client wil continue with home program to work on paying bill and phone use to assist with organization at home. Client's insurance shows he is stil eligible for more OT service, but with new goals. lien can use following resources: wif daughter, bank customer sevice and continued therapy services (He attends to ‘multiple different therapy services).