A feline SOAP Note

This is a re-post in honor of Ravi. I think this is the one he said he liked…

http://blog.missawesomeness.com/2007/07/nikki-feline-soap-note.html (for original, including amazing picture, although meat of it copy/pasted here)
Initial evaluation with Nikki, a 17-year-old Tortoiseshell feline, home visit.

S: Nikki voiced her complaints of of arthritic pain in her joints
as well as stated she always has a generalized sense of anxiety.
Reports hobbies of watching ants, biting butts, sitting in windows,
and meowing.

O: Nikki was observed taking Amytriptline to calm herself. She
raced from room to room, meowing, as her owner cleaned. She jumped gingerly during window-ground transfers, and appeared agitated.
She bit the wrist of the owner’s friend and did not express remorse.

A: Nikki appears to have difficulty initiating appropriate social
interactions with other felines and humans. Sensory integration
approaches, such as a brush protocol and heating pad may help her
both with her anxiety and arthritic pain. ABA therapy could be used
to teach her to stop biting. She would also benefit from consistent
monitoring of her medications.

P: Discuss plan of care with owner & veterinarian. Visit home
again within one week to determine other possible negative environmental
influences. Train owner in proper sensory integration techniques, including Wilbarger brush protocol.
STG: Reduce Nikki’s biting by 50% using SI techniques, within two weeks.

Feb 02, 2013 | Category: Occupational Therapy | Comments: none

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