Medical Transcription Rehab SOAP Note Sample Report #1
SUBJECTIVE: The patient is without complaints, except that she wants to know when the tracheostomy tube can be removed and the laryngeal prosthesis used. She states that Dr. Doe knows how to manage this. She also mentioned a Dr. Smith but then stated Dr. Jones would be the best person to contact. Her daughter and granddaughter are at the bedside and report no complaints by the patient. There are able to lip breathe the patient fairly well.
OBJECTIVE: Temperature 97 degrees, pulse 86, respirations 22 and blood pressure 115/78. The head and neck examination showed pupils equal, round and reactive to light, although the patient was noted to have a slight difference in the left cornea. She is edentulous. A #6 Shiley tracheostomy tube was noted with the cuff down. A high-humidity trach collar was in place providing 35% oxygen. The pulse oximeter showed 97% oxygen saturation. There was no stridor. There was no accessory muscle use for respiration. Heart and lung examinations were within normal limits, except for scattered rhonchi. This improved after suctioning of thick, white sputum. The heart had a regular rate and rhythm without murmur. The abdomen was slightly distended and hyperresonant to percussion. A PEG tube was in place. There was no guarding. A Foley catheter was also in place. No rectal sensation was noted and soft stool was in the rectal vault. A PICC line was noted in the right arm. There was no lower extremity edema.
Neurologic examination showed the patient to be alert and oriented x3 with mental status grossly intact. She was able to follow conversations and was able to mouth words. There was no vocalization. Cranial nerves II through XII were grossly intact and a laryngectomy site was noted. Normal tone was noted in the proximal upper extremities. Biceps strength was 4+/5 bilaterally. No other voluntary muscle contraction was noted. The sensory examination was as noted by Dr. Doe in his admission history and physical. The lower extremities were flaccid with no voluntary muscle contraction. There was no ankle clonus. There was no calf asymmetry. The patient had fair head control.
ASSESSMENT/PLAN:
1. Rehabilitation: The patient was admitted today to begin comprehensive rehabilitation for the late effects of spinal cord injury. Neurologic examination is consistent with C4 sensory, C5 motor complete tetraplegia, ASIA-A. There is a zone of partial preservation in C5-C6 and T2-T3 as far as sensory is concerned. Comprehensive inpatient rehabilitation will work to maximize the patient’s functional abilities so that she becomes independent directing her care. The hope is that the patient will require minimum-to-moderate assistance with feeding and grooming with balanced forearm orthosis. Hopefully, she will be able to provide maximum assistance with transfers. Wheelchair seating and positioning will be performed with the hope the patient will be independent with power wheelchair mobility. Rehabilitation will also work to maximize her communication skills. We will also work towards a regulated bowel/bladder program, provide patient/family education, optimize her overall medical care, prevent contractures/decubitus ulcers/DVTs, address issues related to sexuality and disability and discharge planning. We will also make sure that her sleep and pain are under good control.
2. Rehabilitation potential: Fair.
3. Estimated length of stay: Four to six weeks.
4. Epidural abscess: Currently, the patient is afebrile. She continues to receive IV vancomycin and ceftriaxone. We will consult Dr. Smith and determine how long the patient will need to be on antibiotics. The patient and family are aware that there has been further neurologic decline since the initial consultation by Dr. Doe. We will continue to follow the neurologic status as well as respiratory parameters. A decline in respiratory parameters may necessitate placement on a ventilator.
5. Pulmonary: Continues with some congestion. We will obtain an admission chest x-ray and perform aggressive pulmonary toilet. We will contact Dr. Doe to look into either moving the tracheostomy tube or advising on how the laryngeal prosthesis can be used or when it should be used by the patient.
6. Deep venous thrombosis prevention: We will continue Fragmin for now.
7. Neurogenic bowel/bladder management: We will look towards bladder training and removal of the Foley catheter. We will perform intermittent catheterization every 4-6 hours to keep volumes less than 450 mL. We will work towards a regulated bowel program.
8. Stage II sacral decubitus ulcer: Stable with Tegasorb. Continue turning every 2 hours.
9. Hypothyroidism: Noted by history. We will provide thyroid replacement medications.
10. Pain: Under good control with fentanyl. Continue present management.
11. Dysphagia: Noted to start after the laryngectomy. Currently with a PEG tube.
Medical Transcription Rehab SOAP Note Sample Report #2
SUBJECTIVE FINDINGS: The patient said that he slept well last night. He was able to tolerate the CPAP machine without any difficulty.
OBJECTIVE FINDINGS:
General: The patient is a well-developed, obese male, in no apparent distress.
Vital signs: Temperature 98.6 degrees, pulse 72, respirations 18, and blood pressure 158/80.
HEENT: Head is normocephalic.
Neck: Supple to palpation.
Extremities: Examination of the extremities shows incision site to be healing well without any sign of infection or skin breakdown. Peripheral pulses are intact. Minimal edema in the left lower extremity. Homans sign is absent.
FUNCTIONAL STATUS: Functionally, the patient is able to demonstrate improvement with full range of motion, -5 to 80 degrees of flexion actively and 86 degrees passively. His functional gait has advanced 200 feet with the use of front-wheel walker with supervision. He is supervised level with his bedside commode transfers and contact guard assistance with shower chair transfers. He is modified independent level with his eating and setup with his grooming skills. He requires moderate assistance with lower body dressing.
IMPRESSION:
1. Polyarthritis.
2. Left total knee arthroplasty.
3. Status post coronary artery bypass graft.
4. Chronic obstructive pulmonary disease.
PLAN: Continue with current treatment program. We will continue to monitor the patient’s hypertension, which is still out of control.
Medical Transcription Rehab SOAP Note Sample Report #3
SUBJECTIVE: The patient is without complaints, except there is concern from the nursing staff that he might be constipated. The patient denies any GI upset. He states he has poor appetite.
OBJECTIVE: Temperature 97.4 degrees, pulse 92, respirations 18, and blood pressure 90/62. The head and neck examination showed temporal wasting, which was unchanged from admission. He is awake, alert, and engaging. He has a moist nasal and oral mucosa. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. A PEG tube was in place. A Foley catheter was in place and drained to a urine collection bag. There was no apparent lower extremity edema. The patient is noted to have a stage III sacral decubitus ulcer measuring 6.5 x 5.5 x 1 cm deep. Within that was a 3.6 x 2.8 eschar slightly to the left of midline. Excellent granulation tissue ringed the decubitus ulcer side. Also, in the 5 o’clock position was the formation of granulation tissue within the decubitus ulcer. There was no foul odor. Bilateral heel blood blisters have evolved. The left heel has a stage II decubitus ulcer measuring 5.5 x 3.2 cm and within that a blood blister scab of 2.5 x 1.2 cm. At the right heel, there was a 1.2 x 2 cm stage II decubitus ulcer and within that a 1. 7 x 0.4 cm scab. No induration was noted around the heels. The scaly skin on the soles of both feet is now gone.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient is attempting to increase his participation in therapies. He sees the progress he has made and is more engaging to learn about improving his condition and reduce his need for assistance. Continue comprehensive inpatient rehabilitation.
2. Nutrition: Remains poor in terms of oral intake. He is receiving supplemental tube feedings. We will obtain a comprehensive metabolic panel to aid with the nutritionist, who will be assessing the patient tomorrow.
3. Stage III sacral decubitus ulcer: Continues to show good granulation tissue formation along the edges. Will need to be debrided in the future though at the present there is no edge to start the blunt debridement. We will hold off on sharp debridement. We will continue to work to enhance the nutritional status.
4. Bilateral heel blood blisters: Now evolving into areas of excellent granulation tissue formation and a shrinking of the size of the scab. We will begin Adaptic dressings to be changed twice a day. This should foster the stratification of the skin. We will debride the dry blood blisters when they are more appropriate to be debrided.
5. Bowel/bladder management: Efforts continue to work on regulated programs. The patient has not had a bowel movement over the past 24 hours. There is no evidence of an acute abdomen. We will obtain an abdominal film to see if there is evidence of constipation. Perhaps, the patient has been cleaned out with the aggressive bowel program and has nothing else to be cleaned out because his intake has been poor. We will follow.
Medical Transcription Rehab SOAP Note Sample Report #4
SUBJECTIVE: The patient is without complaint. However, he notes some muscle tightness and wonders if another trigger point injection can be done.
OBJECTIVE: Temperature 98.4 degrees, pulse 64, respirations 18, and blood pressure 94/54. The head and neck examination was unremarkable, except the patient is wearing a Minerva brace. Heart and lung examinations were within normal limits. There was no paradoxical pattern of respiration. The abdomen was soft, nontender, with active bowel sounds. Thigh-high TED hose was worn. There was no lower extremity edema. A bone stimulator was in place over the neck. The patient was noted to have myofascial tender points over the infraspinatus and teres minor muscles on the left. There were also some tender points in the upper trapezius muscle.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. He is trying to incorporate hand use in his functional tasks. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with the Minerva brace. Continue present management.
3. Stage II sacral decubitus ulcer: Healing well. Continue the Accuzyme and Xenaderm as written.
4. Dysphagia: Stable. Continue dysphagia III stage II liquids.
5. Depression: Upbeat and engaging. We will continue Paxil and supportive therapy.
6. Left shoulder pain: Significant for myofascial tender points. We will perform myofascial trigger point deactivation technique with acupuncture needles.
7. Spasticity: Under fair control. Continue baclofen as written.
Medical Transcription Rehab SOAP Note Sample Report #5
SUBJECTIVE: The patient was seen today in followup for his tetraplegia. He reports he is doing well and denies any significant new problems. He does mention he has had a bit of anxiety last night, usually occurring with changes in staff and routine. He reports that he is otherwise comfortable. His anxiety is generally reduced, and he has no other systemic complaint.
OBJECTIVE:
VITAL SIGNS: On evaluation, his temperature is 98.4, pulse 92, respirations 18, blood pressure 104/70.
GENERAL: Overall, he is pleasant, comfortable, does not appear anxious at the present time. He is cooperative with my examination, and there does not appear to be any evidence of mood or thought disorder
LUNGS: On auscultation, clear.
HEART: Regular in rate. No murmur, gallop or rub seen.
ABDOMEN: Soft, nontender, no masses seen.
LABORATORY DATA: His recent laboratory investigation came up positive for fecal occult blood, but we note that his hemoglobin appears to be rising steadily over the past couple of weeks.
ASSESSMENT AND PLAN:
1. As far as his tetraplegia, he is stable and improving slightly. He has much more improvement on his left than right side.
2. As far as his neurogenic bowel and bladder, these are ongoing issues with the home team and being managed day by day. No urgent issues here.
3. No new medical problems seen.
4. As far as his positive fecal occult blood, it is a bit hard to know how to take this. He does not have any gross blood, he is on a bowel program, his hemoglobin is rising, thus we will observe for the present time.
5. Continue comprehensive rehabilitation program with goal to discharge as per the home team.
Medical Transcription Rehab SOAP Note Sample Report #6
SUBJECTIVE: The patient is without complaints, except for some mild tiredness. She attributes this to some right lateral thigh pain.
OBJECTIVE: Temperature 97.4, pulse 88, respirations 20, and blood pressure 156/88. The head and neck examination was unremarkable, except the patient is wearing a SOMI brace. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. Mild tenderness to palpation was noted at times in the right popliteal fossa and at other times along the iliotibial band on the right. There was no pain with hip internal or external rotation. However, there were times when the patient complains of hip pain. There was no lower extremity edema.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. Continue to work on strength and coordination. Continue to maximize the functional abilities. Continue comprehensive inpatient rehabilitation.
2. Spine stability: Stable with the SOMI brace.
3. Dementia: Stable. However, she has great difficulty in describing her pain complaints consistently. We will continue to monitor.
4. Hypertension: Slightly elevated today. This was before medications. We will continue to monitor her blood pressure.
5. Right popliteal fossa/lateral thigh pain: Noted. We will obtain right pelvis and hip films to make sure there is no fracture or subluxation. We will then be able to use local heat as well as deep heat along with a stretching program.
Medical Transcription Rehab SOAP Note Sample Report #7
SUBJECTIVE: The patient is without complaints. She is curious why her left arm is not working; although, she acknowledges that she has had a stroke affecting the side.
OBJECTIVE: Temperature 98.6 degrees, pulse 74, respirations 18, and blood pressure 142/72. The head and neck examination showed a mild left facial droop, but no drooling. There is no left shoulder subluxation. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. There was no lower extremity edema. The patient is noted to have emerging left upper extremity tone, but no voluntary movement.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. She requires cues for attending to the left side at times. Continue comprehensive inpatient rehabilitation and discharge planning.
2. Stroke prevention: No new stroke findings. Continue Aggrenox as written.
3. Deep venous thrombosis prevention. Continue Fragmin as written.
4. Nutrition: The patient is tolerating her NCC diet. She is somewhat disappointed that this is a low-cholesterol diet. She acknowledges that she has cardiac disease, which requires her to be on a low-cholesterol diet.
5. Depression: Somewhat improved. Continue Zoloft and supportive therapy. The patient has resumed taking her medications.
6. Right cerebrovascular accident/left hemiparesis: A 10-15 minute discussion was held with the patient with regards to the etiology of her stroke and recovery of her stroke. She appreciated this discussion.
Medical Transcription Rehab SOAP Note Sample Report #8
SUBJECTIVE: The patient is without complaints. He denies any chest pain or shortness of breath. He again is a bit concerned about the left leg swelling though this is unchanged.
OBJECTIVE: Temperature 97.2 degrees, pulse 102, respirations 22, and blood pressure 122/82. The patient is receiving 2 liters of oxygen via nasal cannula. There is no accessory muscle use for respiration. He is noted to have distant heart and lung sounds. However, there were no rales, rhonchi, or wheezes. The abdomen was soft, nontender, with active bowel sounds. Calf circumference (10 cm below the tibial tuberosity) was 33 cm in the right and 35 cm on the left. No cords or Homans sign was noted. However, 1+ left lower extremity edema was noted. The patient’s left hip incision is intact.
ASSESSMENT AND PLAN:
1. Rehabilitation: The patient continues to participate fully in all therapy sessions. A team conference will be held tomorrow to review his functional goals and progress. Continue comprehensive inpatient rehabilitation and discharge planning.
2. Left subtrochanteric fracture: Stable. Continue weightbearing as tolerated.
3. Left lower extremity edema: Noted. The patient has had previous Doppler studies, which were negative. We will continue to follow for now.
4. Chronic obstructive pulmonary disease: Stable. Continue 2 liters of oxygen via nasal cannula. We will titrate to an oxygen saturation of 92%.
5. Multiple medical problems: Continues to be followed by Dr. John Doe.
Medical Transcription Rehab SOAP Note Sample Report #9
SUBJECTIVE: The patient is without complaints. He is tolerating therapy well. He states that he has decreased hip pain and swelling.
OBJECTIVE FINDINGS:
General: The patient is a well-developed, well-nourished male, in no apparent distress.
Vital signs: Temperature 98.6 degrees, pulse 74, respirations 18, and blood pressure 154/82.
HEENT: Head is normocephalic.
Neck: Supple to palpation.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Normoactive bowel sounds.
Extremities: Incision site is healing well without any sign of infection or skin breakdown. The patient has 1+ edema in the right lower extremity. Peripheral pulses are intact and Homans sign is absent.
FUNCTIONAL STATUS: Functionally, the patient is at a modified independent level with his bed mobility and supervised with ambulation. He is currently able to ambulate 100 to 150 feet, toe-touch weightbearing, and the patient is showing improved compliance with his weightbearing restrictions. Sitting balance is at an independent level, and he is at a moderate assistance level with standing. Transfers are at a supervised level. For his self-care skills, he is supervised with his eating, grooming, upper and lower body dressing skills, toileting, and bedside commode transfers. He still requires some contact guard assistance with transferring in and out of the shower.
IMPRESSION:
1. Degenerative joint disease of the right hip, status post right total hip replacement.
2. Hypertension.
3. Benign prostatic hypertrophy.
4. Chronic obstructive pulmonary disease.
Laboratory report showed anticardiolipin testing is within normal limits. His vitamin B12 and folate are within normal limits.
IMPRESSION:
1. Cerebrovascular accident.
2. Dysphagia.
PLAN: We will continue current treatment program. We will review at this point the patient’s overall swallow and follow up on his blood sugars and stabilize them.
