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Walker safety documentation

answer

Pt educated on walker safety principles in order to decrease risk of falls and increase independence during ADL/IADL routine.

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Walker safety focus:

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environmental barriers such as throw rugs, cords, furniture; weight shift and stability during extended reach activities; transportation of objects; and functional transfers.

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Walker safety focus continued...

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Pt able to identify environmental barriers at home and in the community- and able to provide strategies for modifications to surrounding and routine for increased safety.

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Adaptive equipment training

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Pt was educated on AE to increase independence during self care routines and decrease risk of falls during dynamic balance activities requiring extended reach.

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Adaptive training focus:

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Sock aid, reacher, dressing stick, long-handled shoe horn, and long-handled bathing stick to improve independence in LB ADLs.

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Providing handouts

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Pt was provided with printed handouts for walker safety and adaptive equipment in order to increase recall and compliance. Pt verbalized understanding of all education on this date, and reported no further questions.

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Upper body exercises verbal cues

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Pt required verbal cues for technique with focus on appropriate speed, breathing techniques and joint positioning during exercise.

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Shoulder sugery Pendulums and ROM

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Pt stood EOB with min assist for balance, leaning left forearm on back of the chair, to attempt pendulum exercises for right shoulder. Pt required max verbal cues and tactile cues for technique due to significant muscle guarding when attempting to all UE to hang freely.

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Shoulder sugery Pendulums and ROM continued

answer

Over a period of 15 minutes, pt able to allow modest gravity-assisted movement of right shoulder in horizontal, vertical, and circular patterns.

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Shoulder sugery Pendulums and ROM in sitting continued

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Pt then returned to seated position at edge of bed to complete active/active assisted range of motion for elbow flexion/extension, wrist flexion/extension, and composite fist/extension exercises.

question

Shoulder surgery at end of session

answer

Reapplied and adjusted straps on shoulder sling at end of session. Added pillow case under straps to protect skin integrity. Pt reported comfortable fit. Provided printed handouts to increase compliance for continued pendulum and elbow/wrist/hand exercises. Verbalized understanding of same and had no further questions.

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Recommendations and inpatient goals for total hip replacement (THA)

answer

Recommended continued OT services in skilled inpatient setting in order to address walker safety, functional transfers , adaptive equipment use, adherence to total hip precautions with good balance during functional activity in sitting and standing, and ADL retraining for safe return home.

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Goals for THA

answer

Pt will verbalize >/= 3 walker safety principles in order to decrease risk of falls during functional transfers and functional mobility. Pt will identify and demonstrate good accuracy for use of >/= 3 pieces of AE utilized for dressing and bathing.

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Goals for THA continued

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Pt will complete toileting with CGA and toilet transfer with min assist x1 person. Pt will stand with CGA for >/=3 minutes to complete simple grooming activity. Pt will identify 3/3 total hip precautions without verbal cues.

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Higher level CVA Short term goals:

answer

Pt will increase right hand strength to 80 pounds in order to sustain grip of large/heavy objects (i.e grocery bags) during course of typical IADL routine. Pt will increase Right shoulder extension, abduction, adduction, external rotation to 5/5 strength in order to move/handle objects and efficiently place hand as needed during extended reach patterns (i.e. driving)

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Higher level CVA Short term goals: continued

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Pt will complete right hand 9-hole peg test with score of

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Higher level CVA long-term goals:

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Pt will demonstrate 5/5 muscle grade for all right shoulder movement patterns. Pt will demonstrate increased right grip strength >/=83 pounds.

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Higher level CVA long-term goals: continued

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Pt will demonstrate increase fine motor coordination to produce legible handwriting and typed documents within employers assigned time frame. Pt will demonstrate good dynamic standing and sitting balance in order to gather/move objects from floor to overhead as needed, without loss of balance or dropped objects.

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Hand strengthening/ROM/Desensitization goals: Short term goals

answer

Pt will verbalize understanding of techniques/ purpose of activities developed for home exercise program, and provide return demo of each with good accuracy. Pt will increase right 3rd digit MCP flexion by >/=5 degrees and PIP flexion by >/=10 degrees. Pt will increase right 4th digit PIP flexion by >/=7 degrees

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Hand strengthening/ROM/Desensitization goals: Short term goals continued

answer

Pt will increase right grip strength by >/=10 pounds. Pt will increase right hand 3 jaw chuck pinch by >/=5 pounds. Pt will identify at least 5 desensitization techniques to reduce pain in right 3rd digit and demonstrate each with good accuracy.

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Hand strengthening/ROM/Desensitization goals: Long term goals

answer

Pt will report 100% compliance with HEP in order to increase ROM, strength, and promote desensitization of right 3rd digit in order to handle/carry/move objects as needed for ADL and IADL routines. Pt will increase right grip strength to >/= 40 pounds without increase pain > 4/10 in order to carry/push/pull objects without assist of left hand and no drops.

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Hand strengthening/ROM/Desensitization goals: Long term goals continued

answer

Pt will increase right 3rd and 4th digit ROM to provide sufficient functional grasp in full/hook/straight fist patterns to handle/manipulate objects without drops. Pt will report left hand pain/sensitivity /=25 pounds during work activity.

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G- code statement:

answer

Severity of impairment determined by observation of patients performance during functional activity and clinical judgement during course of evaluation. Please refer to the accompanying OT evaluation for details.

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Combined plan of care and goals statement

answer

Following are long and short term goals for the occupational therapy plan of care developed to address the problems noted above:

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Progress note opening statement with plan of care verbiage:

answer

Following are progress and barriers towards goals for the occupational therapy plan of care during the reporting period ___ to ___. These goals address the following problems:

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Comprehensive long term statement

answer

... will complete ADL/IADL routines at home with mother with min assist to SBA, without demonstration of trantrum (including screaming, crying, hitting, kicking, head banging, etc); as well as participate in pre-school with good demonstration of self regulation to attend to task, produce legible handwriting, and transition smoothly.

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Pediatric long term goals: for 2 year old

answer

Child will transition between preferred and non-preferred activities with /= 6 pre-handwriting shapes with

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Pediatric long term goals: for 2 year old Continued

answer

Child will attend to a therapist or teacher chosen activity x 10 minutes with

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