Hand Therapy SOAP Notes & Documentation

Patient reports "the numbness in my fingers is so much better already" and rates incisional tenderness at 3/10 with pressure. Denies night symptoms that were present pre-operatively. States she is sleeping through the night without waking from numbness. Reports pillar pain with gripping activities. Patient motivated to return to work as an administrative assistant. Performing HEP 3x daily as instructed.

Incision: Well-healed, no signs of infection. Scar hypersensitive to light touch. Mild scar adhesion noted at proximal palm.
Edema: Minimal swelling at thenar eminence. Figure-8 wrist measurement 15.5cm (from 16.2cm at initial visit).
ROM (AROM): Wrist flexion 55 degrees, extension 50 degrees. Full finger ROM. Composite fist within functional limits.
Sensation: Two-point discrimination index finger 5mm (improved from 8mm pre-op), middle finger 6mm.
Strength: Grip strength deferred per protocol. Pinch strength deferred.
Treatment: Scar massage and desensitization, retrograde massage for edema, AROM wrist and digits, tendon gliding exercises, nerve gliding exercises, patient education on activity modification and gradual return to typing.

Patient progressing well post carpal tunnel release with resolution of night symptoms and improved two-point discrimination. Edema improving with retrograde massage. Scar hypersensitivity expected at this stage and responding to desensitization program. Pillar pain common post-operatively and managed with activity modification. Continues to require skilled OT for scar management, edema control, ROM progression, and gradual return to work activities including typing and fine motor tasks.

Continue OT 2x/week for 4 weeks. Progress scar management with silicone gel and compression. Begin gentle grip strengthening at week 4 if appropriate. Initiate work simulation activities (typing, writing) with frequent breaks. Continue nerve gliding and tendon gliding exercises. Update HEP with progressive grip exercises. Goal: return to full work duties by week 8 post-op.

Patient reports "the clicking is less frequent" and rates pain at 2/10 with gripping, down from 5/10 at initial evaluation. States the finger no longer locks in the morning since wearing the MCP blocking splint at night. Patient compliant with splint wear schedule. Notes improvement with activity modification at work (construction foreman - reduced tool use). Occasional catching with forceful grip but no locking episodes this week.

Observation: No visible nodule at A1 pulley today. Minimal tenderness to palpation at MCP flexor crease.
Triggering: Grade 2 (catching, self-correctable) with resisted grip. No locking observed during session.
ROM (AROM): Ring finger MCP 0-90 degrees (improved from 0-80 degrees), PIP/DIP full. No extension lag.
Strength: Grip strength 85 lbs (from 75 lbs), limited by pain avoidance.
Treatment: Soft tissue mobilization to flexor tendon sheath, AROM exercises, differential tendon gliding, eccentric finger exercises, splint adjustment and wear schedule review, ergonomic education for tool use.

Patient demonstrating good progress with conservative management of trigger finger. Triggering grade reduced from Grade 3 to Grade 2 over past 2 weeks. Morning locking resolved with nighttime MCP blocking splint. ROM improving with decreased pain at A1 pulley. Patient compliant with splint wear and activity modifications. Continues to require skilled OT for tendon gliding optimization, splint management, and work activity modification to avoid surgical intervention.

Continue OT 1x/week for 3 more visits. Maintain nighttime splint wear. Progress tendon gliding exercises. Consider daytime buddy taping if triggering persists with work activities. If no further improvement in 3 weeks, discuss corticosteroid injection referral with physician. Goal: eliminate triggering with conservative management and return to full work activities without symptoms.

Patient reports "my wrist feels so stiff but getting better each day" and rates pain at 4/10 with end-range stretching. States she can now button her shirt but has difficulty with jar lids and carrying grocery bags. Reports performing HEP 4x daily. Concerned about getting full motion back for gardening season. Denies numbness or tingling.

Edema: Moderate dorsal hand edema. Figure-8 measurement 17.2cm (from 18.0cm last visit). Volumetric measurement deferred.
ROM (AROM): Wrist flexion 40 degrees (from 30 degrees), extension 35 degrees (from 25 degrees), supination 60 degrees, pronation 70 degrees. Composite finger flexion to distal palmar crease.
ROM (PROM): Wrist flexion 50 degrees, extension 45 degrees with firm end-feel.
Strength: Grip strength 18 lbs (uninvolved side 52 lbs). Pinch strength index 4 lbs.
Treatment: Moist heat, AROM/PROM all planes, joint mobilization Grade III to radiocarpal and midcarpal joints, scar tissue mobilization at cast edges, retrograde massage, functional activity training (simulated buttoning, jar opening with adaptive equipment), HEP progression.

Patient making steady gains in ROM following cast removal for distal radius fracture. Wrist flexion improved 10 degrees and extension improved 10 degrees since last visit. Edema continuing to decrease with elevation and compression. Joint stiffness responding well to mobilization techniques. Strength significantly decreased compared to uninvolved side, expected at this stage. Continues to require skilled OT for joint mobilization, ROM progression, edema management, and strengthening to return to functional use of dominant hand.

Continue OT 2x/week for 6 weeks. Progress joint mobilization as ROM improves. Begin progressive grip and pinch strengthening next visit. Initiate functional activities with light resistance (gardening tools, jar opening). Consider static progressive splinting if ROM plateaus. Update HEP with strengthening exercises. Goal: achieve functional wrist ROM (60 degrees flexion, 60 degrees extension) and grip strength 75% of uninvolved side within 8 weeks.