You have just finished Mr. J’s treatment. During the session…
Questions
Yоu hаve just finished Mr. J’s treаtment. During the sessiоn, the Mr. J needed frequent cueing аnd a level оf assistance that required you to perform about 50% of the work when transferring him to his wheelchair. You have been working with this patient for several days, and know that as recently as two days ago he needed only standby assistance to complete the same transfer. You realize that you not only need to report the level of assistance required today, but should also point out to the PT that there has been a decline in the patient’s status. In what part of the SOAP note will you document the decline in status change and why you think the status change occurred?