A structured assessment is crucial in managing patients with post-stroke hemiplegia. Accurate documentation ensures effective rehabilitation planning, progress tracking, and interprofessional communication.
🔹 1. Initial Observation
- Note facial symmetry, posture, involuntary movements, and level of consciousness.
- Assess for communication issues (aphasia/dysarthria) or cognitive impairment.
🔹 2. Subjective Assessment
- Chief complaint (in patient/caregiver words)
- Onset, duration, and side of hemiplegia
- Any history of previous strokes, falls, or seizures
- Functional limitations in ADLs (toileting, dressing, walking)
🔹 3. Objective Assessment
- Motor Examination: Tone (Modified Ashworth Scale), strength (MMT), reflexes
- Sensory Evaluation: Touch, pain, proprioception
- Coordination: Finger-to-nose, heel-to-shin
- Balance: Static & dynamic (Berg Balance Scale or Functional Reach)
- Gait Analysis: If ambulatory
- Functional Scales: FIM, Barthel Index
🔹 4. Goal Setting
- Short-term: e.g., improve sitting balance, initiate standing
- Long-term: e.g., independent ambulation with aid
🔹 5. Documentation Format
Use the SOAP Note format:
S: What patient/caregiver reports
O: Physical findings and scores
A: Your clinical judgment
P: Planned interventions/goals
This approach ensures consistency, medico-legal safety, and clarity in multi-disciplinary setups.
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