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    Augusta Technical College Occupational Therapy Assistant Program

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    api-300158819
    The occupational therapy treatment note summarizes a patient's session on July 31st 2015 from 1:00pm to 2:00pm. The patient states he feels "good" but is very tight. He requires maximum to moderate assistance with activities of daily living such as dressing, bathing, and toileting due to contractures limiting range of motion. The patient can follow some commands and has purposeful cognition, but has deficits in functional balance, mobility, and communication due to spasticity. The goal is for the patient to return on July 3rd to continue working on increasing strength and range of motion to improve independence with activities like sitting, feeding, and transferring.

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    Augusta Technical College Occupational Therapy Assistant Program

    Uploaded by

    api-300158819
    28 views4 pages
    The occupational therapy treatment note summarizes a patient's session on July 31st 2015 from 1:00pm to 2:00pm. The patient states he feels "good" but is very tight. He requires maximum to moderate assistance with activities of daily living such as dressing, bathing, and toileting due to contractures limiting range of motion. The patient can follow some commands and has purposeful cognition, but has deficits in functional balance, mobility, and communication due to spasticity. The goal is for the patient to return on July 3rd to continue working on increasing strength and range of motion to improve independence with activities like sitting, feeding, and transferring.

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    The occupational therapy treatment note summarizes a patient's session on July 31st 2015 from 1:00pm to 2:00pm. The patient states he feels "good" but is very tight. He requires maximum to moderate assistance with activities of daily living such as dressing, bathing, and toileting due to contractures limiting range of motion. The patient can follow some commands and has purposeful cognition, but has deficits in functional balance, mobility, and communication due to spasticity. The goal is for the patient to return on July 3rd to continue working on increasing strength and range of motion to improve independence with activities like sitting, feeding, and transferring.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    28 views4 pages

    Augusta Technical College Occupational Therapy Assistant Program

    Uploaded by

    api-300158819
    The occupational therapy treatment note summarizes a patient's session on July 31st 2015 from 1:00pm to 2:00pm. The patient states he feels "good" but is very tight. He requires maximum to moderate assistance with activities of daily living such as dressing, bathing, and toileting due to contractures limiting range of motion. The patient can follow some commands and has purposeful cognition, but has deficits in functional balance, mobility, and communication due to spasticity. The goal is for the patient to return on July 3rd to continue working on increasing strength and range of motion to improve independence with activities like sitting, feeding, and transferring.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Augusta Technical College

    Occupational Therapy Assistant Program


    Occupational Therapy Services
    Daily treatment note
    Date: July 31st 2015

    Weekly summary

    Discharge summary

    Time: 7:30pm

    S: Pt. states that he feels "good." Client was observed to be laughing and making
    jokes.
    At rest: 0 - 10
    w/activity 0 - 10

    Pain Scale:

    Pain comments: Pt. states that he is very tight.


    O: Pt. seen this date from: 1:00pm to: 2:00pm at: Clinical other:
    ADL STATUS:
    ADL

    RATING

    MEAL SET-UP:

    MAX

    EATING:

    SBA

    GROOMING

    MOD

    BATH/SHOWER

    MAX

    DRESSING UE
    DRESSING LE
    UNDRESSING UE
    UNDRESSING LE
    TOILETING

    MAX
    MAX
    MAX
    MAX
    MAX

    ADL TRANSFERS

    MAX

    BED MOBILITY

    SBA

    W/C MOBILITY

    IND

    WALKER MOBILITY

    N/A

    COGNITION: Purposeful-appropriate

    COMMENTS
    Pt. has 50% use of right UE and 80% use
    of left UE due to contractures
    Pt. can feed self mostly with left UE but
    ROM is very limited
    Pt. can reach and care for 85% of head
    and UE
    Pt. must be transerred and cannot reach
    entire body due to contractures
    Pt. can assist in dressing
    Pt. can assist in dressing
    Pt. can assist in dressing
    Pt. can assist in dressing
    Pt. must be transerred and needs
    assistance to reach toilet care items
    Pt. has sufficient strength to stand with
    assistance for balance. Pt. is max assist
    or mod x 2.
    Patient can use UE and LE strength to
    postion self lying down.
    Pt. uses power wheelchair and navigates
    easily.

    Comments: pt. is alert and


    appropriate in his response and
    answers.

    ORIENTATION: X4 (person/place/time/situation)

    ATTENTION SPAN: Without Redirection

    o
    o

    FOLLOWING COMMANDS: Follows_


    3 -step commands
    Cues required: pt. required cuing to keep his balance during EOB sitting.
    General comments: Pt. performed EOB sitting for 4 min and 6min. Pt. was mod A
    x2 <-> mat table. Pt. performed sit to stand 4 x, navigated different terrain in
    power chair, reached to pick fruit, used nautilus machine to stretch UE with
    grasp 8X 30 sec.

    ADL deficits

    Pain interfering with functional status

    Cognitive/perceptual deficits impacting


    independence/safety
    UE function deficit interfering with functional status

    Functional balance

    Functional mobility

    Functional communication

    Functional problems

    o
    o

    Due to
    spasticity pt.
    has limited use
    of UEs
    Due to
    spacsticity pt.
    has no standing
    balance w/o
    assistance

    Pt.s voice is
    raspy and quiet

    Comments: Pt. tolerated EOB sitting with 4 cues to regain balance. When
    positioning in powerchair pt. required extra time to position in his chair. Pt.
    used left UE only to pick fruit. During nautilus training pt.s RUE lost grasp 3
    times.

    o
    o

    o Comments
    Pt. is mod to
    max assist on
    ADLs

    P: pt. to return July 3rd 2015 to address the following:

    Comments: Pt. will return to OT to continue increasing strength and ROM for
    increasing function such as EOB sitting while grooming, self feeding and
    transferring.

    o
    o
    o

    Signature: James W. Brazelle, OTAS

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