Date of Session: 1/30/2020

SOAP #3

S: When asked if he thought the reminders app is something that he will actually use in the future, the
client stated, “Maybe, we’ll see.”

O: Client participated in education and practice on the use of the “reminders” application and “speak”
feature on his smart phone. He sat in his scooter pulled up to a small table. When using his phone, he
generally held it at about 6-8 inches away from his face. He held his phone with his left hand and
scrolled with his right index finger. When visually scanning his screen, his left eye made jerky
movements. He followed one step directions with max verbal cueing to set an initial reminder in the
“reminders” app. He then followed one step directions to use the “speak” feature with an email, and a
text message requiring max verbal cueing for this as well. Lastly, he required max verbal cues and mod
visual cues (instructions sheet) to set a second reminder in his phone. When he received the reminder
notifications, he acknowledged them and completed the task associated with them with mod verbal
cueing. Through the duration of the session he often made off-topic comments and engaged in
tangential speech, requiring consistent redirection to stay on task. Client accepted and acknowledged
the request for him to complete “homework” through the week of working with those around him to set
reminders on his phone. Client took handout with instructions for “reminders” app and the speak
feature.

A: Client demonstrated visual deficits as evidenced by the proximity of his phone to his eyes, and the
jerky movements observed in his left eye during visual scanning. He demonstrated working memory
deficits as evidenced by his inability to remember any of the steps associated with setting a reminder
the second time following instructions. He also demonstrated poor attention and focus as evidenced by
his consistent off-topic and tangential speech; requiring significant redirection and reminders to stay on
task. Client may have difficulties with learning new tasks but may be able to learn with consistent
repetition based on literature associated with MS and cognitive deficits.

P: Client will continue to be seen for skilled OT services 1x/week for 5 more weeks to continue working
on using his phone as a reliable and useful tool to use for safety, and efficiency in his daily life. Student
therapist will follow up with client mid-week to ask about his completion of his “homework.” Student
therapist will follow up again at next session to determine if client is able to learn new skills with
repetition.