작업치료 SOAP

소개글

"작업치료 SOAP"에 대한 내용입니다.

목차

1. Subjective information

2. Objective information
1) Mental status
2) Physical status
3) Hand function
4) Sensory
5) Cognition
6) Perception
7) ADL

3. Assessment

4. Plan

본문내용

< Subjective information >
1. Name :최00
2. 성별/연령 :M/00
3. Dx :Cerebral infarction (Rt. hemiplegia)
4. On set : 2000.00.00
5. C/C :Broca’s aphasia, Rt. arm의 pain
6. PI :
7. P/HX :DM(-), HTN(-), MI(-)
8. Meds : 없음
9. Family History :
10. Care giver :
11. Dominant hand : * pre-dominant : Rt. hand / Post-dominant : Lt. hand
12. Home situation : 주택 (엘리베이터 X )
13. Pre - Occupation :
14. Smoking(-), Alcohol(+)
15. Education :
16. Attitude :

< Objective information >
1. Mental status : Alert
2. Physical status

참고 자료

없음