OT Cheat Sheet – Flashcards

Unlock all answers in this set

Unlock answers
question
Walker safety documentation
answer
Pt educated on walker safety principles in order to decrease risk of falls and increase independence during ADL/IADL routine.
question
Walker safety focus:
answer
environmental barriers such as throw rugs, cords, furniture; weight shift and stability during extended reach activities; transportation of objects; and functional transfers.
question
Walker safety focus continued...
answer
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.
question
Adaptive equipment training
answer
Pt was educated on AE to increase independence during self care routines and decrease risk of falls during dynamic balance activities requiring extended reach.
question
Adaptive training focus:
answer
Sock aid, reacher, dressing stick, long-handled shoe horn, and long-handled bathing stick to improve independence in LB ADLs.
question
Providing handouts
answer
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.
question
Upper body exercises verbal cues
answer
Pt required verbal cues for technique with focus on appropriate speed, breathing techniques and joint positioning during exercise.
question
Shoulder sugery Pendulums and ROM
answer
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.
question
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.
question
Shoulder sugery Pendulums and ROM in sitting continued
answer
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.
question
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.
question
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.
question
Goals for THA continued
answer
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.
question
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)
question
Higher level CVA Short term goals: continued
answer
Pt will complete right hand 9-hole peg test with score of
question
Higher level CVA long-term goals:
answer
Pt will demonstrate 5/5 muscle grade for all right shoulder movement patterns. Pt will demonstrate increased right grip strength >/=83 pounds.
question
Higher level CVA long-term goals: continued
answer
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.
question
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
question
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.
question
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.
question
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.
question
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.
question
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:
question
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:
question
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.
question
Pediatric long term goals: for 2 year old
answer
Child will transition between preferred and non-preferred activities with /= 6 pre-handwriting shapes with
question
Pediatric long term goals: for 2 year old Continued
answer
Child will attend to a therapist or teacher chosen activity x 10 minutes with
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New