Wrist Injury SOAP Notes for Physical Therapists

HISTORY OF PRESENT ILLNESS: The client reports that they originally sustained the injury on {formdate: MMM Do, YYYY} when they fell and injured their wrist. They were evaluated at Urgent Care/ER where X-rays identified a left distal radius fracture. They were placed in a splint, referred to Dr. {formtext: name=DoctorName}, and surgery was recommended. The patient presents to hand therapy today for their post-operative initial evaluation and treatment.

DX/SURGERY: {formtext: name=dxsurgery; default=Right/Left distal radius fracture S/P ORIF; cols=35}

DOS: {formparagraph: name=dos}

PRIMARY COMPLAINTS: {formparagraph: name=primarycomplaints; cols=35; rows=4}

PRIOR FUNCTIONAL STATUS: {formparagraph: name=priorstatus; cols=35; rows=4}

CURRENT FUNCTIONAL STATUS: See "Client Information Sheet" for activities that patient reports having difficulty with. Client reports difficulty in the following activities: {formmenu: name=activities; values=eating/using utensils, drinking, bathing/showering, dressing, grooming/toileting, cooking/meal preparation, opening jars & bottles, opening medication, lifting pots & pans, lifting bags & groceries, house cleaning, driving, using keys, writing, keyboarding/mouse use, texting/holding phone, weight-bearing through hand/wrist, gardening/yard work, and hobbies; multiple=yes}

Occupation: {formtext: name=occupation} Social Status: {formtext: name=social status}

PAIN: Pain location: {formtext: name=painlocation} At worst: {formmenu: name=worstpain; values={=seq(1,10)}}/10 Current: {formmenu: name=currentpain; values={=seq(1,10)}}/10 At best: {formmenu: name=bestpain; values={=seq(1,10)}}/10 Pain description: {formtext: name=paindescription} Pain Follow-up Plan: {formparagraph: name=followupplan; cols=35; rows=4}

PATIENT GOALS: {formparagraph: name=patientgoals; cols=35; rows=4}

OBJECTIVE FINDINGS: Handedness: {formmenu: default=Right; Left; Ambidextrous; name=handedness} Wound / Incision Status: {formparagraph: name=woundstatus; cols=35; rows=4} Orthosis/Splint Use: {formparagraph: name=splintuse; cols=35; rows=4} Swelling: {formparagraph: name=swelling; cols=35; rows=4}

Circumferential measurements (cms): Right MCPs: {formtext: name=rightmcps; cols=2}cm Left MCPs: {formtext: name=leftmcps; cols=2}cm Right Wrist: {formtext: name=rightwrist; cols=2}cm Left Wrist: {formtext: name=leftwrist; cols=2}cm

Right Left Digit AROM (extension is 0 unless otherwise indicated): {formparagraph: name=arom; cols=35; rows=4}

Thumb AROM: IP: left: {formtext: name=leftthumbIP} || right: {formtext: name=rightthumbIP} MP: left: {formtext: name=leftthumbMP} || right: {formtext: name=rightthumbIP} Plan abd: left: {formtext: name=leftthumbPlanabd} || right: {formtext: name=rightthumbPlanabd} Palm abd: left: {formtext: name=leftthumbPalmabd} || right: {formtext: name=rightthumbPalmbabd} Opp: left: {formtext: name=leftthumbOpp}|| right: {formtext: name=rightthumbOpp}

Wrist AROM: E: left: {formtext: name=leftwristaromE} || right: {formtext: name=rightwristaromE} F: left: {formtext: name=leftwristaromF} || right: {formtext: name=rightwristaromF} RD: left: {formtext: name=leftwristaromRD} || right: {formtext: name=rightwristaromRD} UD: left: {formtext: name=leftwristaromUD} || right: {formtext: name=righttwristaromUD}

Forearm AROM: Sup: left: {formtext: name=leftforearmaromSup}|| right: {formtext: name=rightforearmaromSup} Pron: left: {formtext: name=leftforearmaromPron} || right: {formtext: name=rightforearmaromPron}

Shoulder AROM: WFL: left: {formtext: name=leftshoulderaromWFL} || right: {formtext: name=rightshoulderaromWFL} Flexion: left: {formtext: name=leftshoulderaromFlexion} || right: {formtext: name=rightshoulderaromFlexion} Extension: left: {formtext: name=leftshoulderaromExtension} || right: {formtext: name=rightshoulderaromExtension} Abduction: left: {formtext: name=leftshoulderaromAbduction} || right: {formtext: name=rightshoulderaromAbduction} IR: left: {formtext: name=leftshoulderaromIR} || right: {formtext: name=rightshoulderaromIR} ER: left: {formtext: name=leftshoulderaromER} || right: {formtext: name=rightshoulderaromER}

Grip and Pinch Strength: {formparagraph: name=grippinch; cols=35; rows=4}

Sensation: {formparagraph: name=sensation; cols=35; rows=4}

Palpation: {formparagraph: name=Palpation; cols=35; rows=4}

MODERATE COMPLEXITY OT CODE: The patient's occupational profile and medical and therapy histories were reviewed through {formtext: name=historyreviewed; cols=35}, and patient intake forms. An analysis was completed of the occupational profile/data based on a detailed assessment. The evaluation identified {formtext: name=resultsidentified; cols=35}. Clinical decision making involved moderate analytic complexity and consideration of several treatment options. Minimal to moderate modification of tasks or assistance was provided. COVID19 precautions in effect.