PTA Therapeutic Skills II - 3303
Lab Skill Assessment #2 - Clinical Documentation - SOAP Note
Patient Name: Nadeen Brown Date: 20/12/17 HCN:123456789 DC
Subjective
Pt attended second PT session with her husband. Pt preferred to have husband wait in the reception
area until the session was over. Pt reported being exhausted from the sleepless night she had yesterday
but was eager and ready to do the best she can in the session. Pt reported a level of pain at 1 out of 10,
10 being pain and 1 being little to no pain. Pt’s treatment goal for her PT sessions are to improve the
quality of her gait cycle (with no gait aids) with the use of FES to tibialis anterior. Pt reported
considering purchasing a gait aid if this treatment session with the FES goes well to than replace her
AFO. PTA provided and reviewed risks, benefits and contraindications of FES with the pt. Pt reported
that she had no contraindications for the use of FES and has intact skin and sensations in her lower
right leg. PTA gained verbal consent to continue with treatment. ---------------------------------------------
Objective
Pt started session sitting on a standard chair. PTA inspected the skin at the area of the tibialis anterior
of the right leg for any skin irritations and then proceeded to wash and dry the area with mild soap and
warm water. PTA placed the single use adhesive electrodes 2 inches apart on the tibialis anterior.
Specifically, one electrode placed on the motor point of the muscle and the other parallel. PTA set
parameters on FES as 200s, 50hz, 5 second on: 25 second off and a 2 second ramp up and down. PTA
connected electrodes to FES and informed pt a second time there may be discomfort and to let the PTA
know. PTA started with having the pt sit and get use to the feel of the FES. Starting at an intensity of 0
and increasing the intensity up to 28 over 4 cycles of 5:25. Pt was comfortable with intensity of 28 and
agreed to continue to next task. PTA had pt stand with left arm resting on a table for support and
connected the manual switch to the FES for the patient. PTA explained the first skill to the pt in full
detail. Pt was to stay stationary and move the right leg only from toe off into mid swing, pause and
then move from mid swing back into toe off. Pt was instructed to hit the manual switch to turn it on
when they lift their toe off the ground and press it again to turn off the FES when they start to bring
their foot back into toe off. Pt completed this skill a total of 15 reps with a 45 second standing rest
after rep 8 before reporting exhaustion and wanting to stop for the day. PTA provided close
supervision behind the pt to start and progressed to close supervision from the side after 5 reps. Pt was
reminded to look up and forward twice and not at the floor. Pt had no sign of foot drop throughout
skill with the use of FES. PTA stopped and disconnected FES from electrodes and removed electrodes
to inspect the skin. Pt skin appeared normal with no irritation. ------------------------------------------------
Analysis
Pt tolerated treatment session well with reports of exhaustion after 15 reps. Pt reported that the next
session she wants to complete 20 reps. Pt took one break for 45 seconds after rep 8. Pt reported post-
therapy pain at a level of 3 out of 10 and reported leg feeling tired. Pt tolerated FES intensity of 28
well with no significant pain and pt reported that next time the intensity could be increased. Pt
successfully had a steady flow moving right leg from toe off to mid swing and back to toe off. Pt
required verbal cues to look forward. Trunk posture throughout session was midline. ---------------------
PTII 3303
PTA Therapeutic Skills II - 3303
Lab Skill Assessment #2 - Clinical Documentation - SOAP Note
Plan
Pt was guided toward the waiting room with husband and left at the reception desk. PTA to follow up
with PT after session to report on the pt overall performance. PTA to discuss and recommend to PT
that the pt could progress to taking a whole step with only the right leg since pt showed a fluid motion
with the half step. Progress to increase the number of reps to 25, due to the pt’s ability to only tolerate
15 reps this session. Slowly build up pt tolerance to strengthen skill. Recommend to PT that the pt
should consider purchasing personal electrodes for use and to advise pt regularly to shave 2 days prior
to next session. Next session will be December 21st 2017 at 10:00am. --------------------------------------
Name of PTA
Nicole Brunne (OTA/PTA Student Durham College) ----------------------------------------------------------------
PTII 3303
