Ashley Thayn

November 2, 2018
University of Utah
Division of Occupational Therapy

SOAP #6
S: “I continue to be pleased with how much I can flatten out my hand… that rubber band
exercise is helping me.”

O: The client reported completing 45 minutes of finger extension exercises for the week and 1
½ - 2 hours of typing practice for the week while including typing letters “a”, “d” and “s” with L
hand. Educated on the purpose of CIMT, specific prepatory and functional L hand exercises,
AROM, and passive stretching techniques for intrinsic hand muscles. Completed prepatory and
functional tasks that required finger flexion, extension, adduction, abduction, opposition,
intrinsic movements, and reaching. Demonstrated difficulty actively extending MCPs when his
wrist is in neutral. Unable to fully actively extend MCPs while keeping PIPs and DIPs flexed. To
actively extending fingers, client compensated by flexing wrist. Demonstrated difficulty actively
flexing DIP and PIP and decreased opposition to fifth digit. Client dropped items three times
while performing pincer grasp. The client was instructed to practice L hand AROM, stretching
exercises and prepatory and functional repetitive hand exercises with wrist in neutral for
homework.

A: The functional use of his LUE is limited by abnormal tone, soft tissue shortening, and
decreased muscle strength in flexors and extensors when engaging in fine motor prepatory and
functional. To actively extend his fingers through the MCP joint, the client uses wrist flexion to
compensate for weakness. Shows an increased tendency to drop items because of a lack of fine
motor skill, proprioception, and absent light touch. Shows decreased endurance for L hand
tasks. One short-term goal has been revised.

P: It is recommended the client be seen for skilled OT services for 2 more sessions to address
LUE motor control and sensory function to improve his ability to engage in meaningful
occupations. Next session, we will address completed homework, LUE motor training, shoelace
tying, functional repetitive movements and reaching tasks, and adding in more L hand letters
when typing.

Goals

LTG 1: By discharge, the client will independently don socks, shoes, and Saebo brace while
incorporating his LUE using compensatory strategies.

STG 1: In 4 sessions, the client will be able to don L shoe over heel while incorporating his LUE
using compensatory strategies with min A. Goal Met 11/9/2018
STG 2: In 6 sessions, the client will able to fasten shoelaces using compensatory strategies with
mod I. Goal Met 10/19/2018

LTG 2: By discharge, the client will increase typing speed by 5 wpm while incorporating LUE
using compensatory strategies.

STG 1: In 5 sessions, the client will use the shift key with L hand and min A, with less than 5
errors per sentence using compensatory strategies. Goal discontinued

STG 1: In 5 sessions, the client will use the shift key with L hand and min VC, with less than 5
errors per sentence using compensatory strategies. Goal Revised 11/9/2018

New Goal STG 1: In 5 sessions, the client will independently use the shift key with L hand, with
less than 5 errors per sentence using compensatory strategies.

STG 2: In 7 sessions, the client will report improved satisfaction with typing performance on
weekly calendar while incorporating use of LUE with mod I. Goal Met

New Goal STG 2: In 7 sessions, the client will type 4 new letters with L hand with mod I.

Name: Ashley Thayn, OTS

Date: November 9, 2018