Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for Central Cord Syndrome (CCS) or evaluation of new symptoms.
SOAP
Subjective (S):
Current Symptoms:
Inquire about any changes in:
Upper extremity strength and function
Sensory changes in the upper extremities
Bowel and bladder function
Pain level
Explore for any new symptoms suggestive of complications (e.g., autonomic dysreflexia symptoms like headaches, sweating).
Rehabilitation Progress:
Briefly assess progress in physical and occupational therapy, including:
Improvements in strength, coordination, and functional abilities
Use of assistive devices
Challenges or limitations encountered
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Motor: Re-evaluate upper extremity strength using a standardized grading system (e.g., ASIA Impairment Scale) to compare with baseline and assess progress. Briefly document lower extremity strength as well.
Sensory: Re-assess light touch, pain, and proprioception in all extremities.
Skin: Inspect skin for any signs of pressure injuries.
Assessment (A):
Functional Improvement:
Describe any improvements in upper extremity strength, function, and independence with activities of daily living (ADLs) based on the history and physical exam findings.
Spasticity:
Assess the presence and severity of spasticity in the upper extremities, which could impact function.
Complications:
Evaluate for any potential complications of CCS, such as:
Autonomic dysreflexia
Deep vein thrombosis (DVT)
Pressure injuries
Contractures
Response to Treatment:
Based on the subjective and objective findings, assess the patient’s response to current treatment modalities (rehabilitation, medications).
Plan (P):
Rehabilitation:
Based on progress and ongoing needs, adjust the physical and occupational therapy plan to:
Continue strengthening and improve coordination in the upper extremities.
Address specific functional limitations with ADLs.
Implement strategies to manage spasticity if needed.
Consider vocational rehabilitation if applicable.
Medications:
Adjust medications for pain management or spasticity control as needed.
Skin Care:
Reinforce the importance of skin care to prevent pressure injuries.
Follow-up:
Schedule follow-up visits based on the patient’s progress and need for ongoing monitoring and rehabilitation adjustments.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., physiatrist, pain management specialist)
Need for additional testing or imaging studies (if indicated)
Patient education regarding ongoing management strategies and potential long-term complications of CCS
Support group resources or counseling referrals if needed
Update on functional status and potential discharge planning (if applicable)