Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cervical spinal cord injury (SCI), evaluation of new symptoms, or rehabilitation visit (specify).
SOAP
Subjective (S):
History of Present Illness:
Briefly summarize the details of the spinal cord injury, including:
Mechanism of injury (e.g., motor vehicle accident, fall)
Level of injury (vertebral level of spinal cord damage)
Date of injury
Inquire about any new or worsening symptoms since the last visit, including:
Pain (location, intensity, character)
Spasticity (muscle stiffness or spasms)
Weakness or paralysis (specify muscle groups affected)
Sensory changes (numbness, tingling, burning)
Bowel or bladder dysfunction (incontinence, difficulty with emptying)
Sexual dysfunction
Difficulty with activities of daily living (ADLs)
Emotional distress (depression, anxiety)
Past Medical History:
Briefly summarize relevant past medical history, including:
Comorbidities that might impact recovery (e.g., respiratory problems, pressure sores)
Previous surgeries related to the SCI
Social History:
Briefly inquire about:
Living situation (accessibility of the home environment)
Social support system
Occupation (pre-injury and potential for return to work)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess:
Motor function (muscle strength, range of motion) in upper and lower extremities using a standardized scale (e.g., ASIA Impairment Scale)
Sensory function (light touch, pain, temperature)
Deep tendon reflexes
Spasticity (tone and clonus)
Skin integrity (checking for pressure sores)
Bowel and bladder function (tone, reflexes)
Imaging Studies (if recent results available):
Briefly mention findings from recent imaging studies (e.g., X-ray, CT scan, MRI scan) if performed, such as:
Level and extent of spinal cord damage
Alignment of the spine
Assessment (A):
Level of Injury:
Confirm the level of spinal cord injury based on history and imaging studies.
Functional Status:
Assess the patient’s current functional status based on motor, sensory, and bowel/bladder function.
Consider using a standardized functional assessment tool (e.g., FIM – Functional Independence Measure).
Complications:
Evaluate for potential complications of SCI, such as:
Deep vein thrombosis (DVT)
Pressure sores
Respiratory infections
Autonomic dysreflexia (sudden, severe increase in blood pressure)
Plan (P):
Rehabilitation Plan:
Outline the ongoing rehabilitation plan to address:
Physical therapy to improve strength, range of motion, and balance.
Occupational therapy to improve ADLs and independence.
Speech therapy if needed for swallowing or communication difficulties.
Assistive technology recommendations to enhance function.
Pain Management:
Consider options for pain management, such as medications, physical therapy modalities, or interventional procedures.
Spasticity Management:
Discuss strategies to manage spasticity, including medications, physical therapy interventions, or botulinum toxin injections.
Bladder and Bowel Management:
Develop a bowel and bladder management program to promote continence or maximize independence with toileting.
Skin Care:
Implement a preventative skin care plan to minimize the risk of pressure sores.
Psychological Support:
Address emotional well-being and consider referral for mental health services if needed.
Social Support and Community Integration:
Explore options for social support and community integration, including support groups or vocational rehabilitation services.
Follow-up:
Schedule regular follow-up visits to monitor progress, address new symptoms, and adjust the rehabilitation plan as needed.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., physiatrist, urologist, psychologist)
Education provided to the patient and family about SCI, management strategies, and expected recovery
Importance of adherence to the rehabilitation program and preventative measures
Prognosis discussion