Dx:

Onset:

Precautions:

Subjective:

____________________________________________________________________________________________________________________________

ROM:

RUE

AROM

PROM

• Scapular protraction/ retraction
• Scapular elevation/ depression
• Shoulder abduction/adduction
• Shoulder flexion/extension
• Elbow flexion/ extension
• Supination/ Pronation
• Wrist flexion/ extension
• Ulnar/ Radial Deviation

LUE

AROM

PROM

• Scapular protraction/ retraction
• Scapular elevation/ depression
• Shoulder abduction/adduction
• Shoulder flexion/extension
• Elbow flexion/ extension
• Supination/ Pronation
• Wrist flexion/ extension
• Ulnar/ Radial Deviation

MMT:

RUE

• Scapula
• Shoulder abduction/adduction
• Shoulder flexion/extension
• Elbow flexion/ extension
• Supination/ Pronation
• Wrist flexion/ extension
• Grip

LUE

• Scapula
• Shoulder abduction/adduction
• Shoulder flexion/extension
• Elbow flexion/ extension
• Supination/ Pronation
• Wrist flexion/ extension
• Grip

 

GMC/FMC in RUE/LUE

R/L Hand Dominant

Praxis ____________________________________________________________________________________________________________

Finger Opposition_______________________________________________________________________________________________

Sitting Balance___________________________________________________________________________________________________

Subluxation_______________________________________________________________________________________________________________

Sensation (paresthesia, numbness, light touch localization) _________________________________________________________

Edema (none, 1+ barely discernible pit, 2+ moderate pitting, 3+ deep pitting, 4+ very deep pitting)_____________

Visual Perception

• Glasses?__________________________________________________________________________________________________________
• Changes in vision since most recent hospitalization (yes/no)
• Hx of glaucoma, macular generation, or cataracts?
• Diplopia? (yes/no)
• Smooth tracking in _______/9 cardinal gaze positions
• Convergence/ Divergence (intact/ not intact)
• Field of Vision via confrontation testing (intact/ not intact)

Pain (if more than 3 make ng aware)

Eating (FIM)

1. 7 I
2. 6 Mod I
3. 5 Supervision (set-up or for safety)
4. 4 Min A (75%-99%)- Steadying Assist
5. 3 Mod A (50%-75%)
6. 2 Max A (25%-50%)
7. 1 Dep (>25%; PEG Tube, IV); A of 2+ people or mechanical lift

Grooming ( __/5= __%= _____FIM score)

1. Hands
2. Face
3. Hair
4. Oral
5. Shave/ Make-up
6. Devices used:

Bathing (__/10= __%= _____FIM score)

1. Chest
2. R Arm
3. L Arm
4. Abdomen
5. Front Peri
6. Back Peri
7. R Upper Leg
8. L Upper Leg
9. L Lower Leg
10. R Lower Leg
11. Devices used:

UB Dressing (__/7= __%= _____FIM score)

1. Shirt One
   1. R Arm
   2. L Arm
   3. Over Head
   4. Arrange in Back
2. Bra
   1. R Arm
   2. L Arm
   3. Fastener
3. Devices used:

LB Dressing (__/13= __%= _____FIM score)

1. Underwear
   1. R Leg
   2. L Leg
   3. Arrange Around Hip
   4. Fastener
2. Pants
   1. R Leg
   2. L Leg
   3. Arrange Around Hip
   4. Fastener
3. Socks
   1. R
   2. L
4. Shoes
   1. R
   2. L
   3. Fasteners
5. Devices

Toileting (__/3= __%= _____FIM score)

1. Pants Down
2. Hygiene
3. Pants Up
4. Device

Transfers 

1. Toilet
   1. Device
2. Tub/ Shower
   1. Device
3. Bed Mobility
   1. supine to sit
   2. side to side rolling
   3. scooting up in bed
4. Sit to stand
5. Stand Pivot
6. Squat Pivot
7. Sliding Board

Comprehension 

• Vision/ Hearing
  • Device

Expression

• Complex ideas, current events, relationships with others
  • Device

Problem-Solving 

• Recognizes problems, makes appropriate decisions, self-corrects errors, safety awareness
  • Device

Memory

• Recognizes familiar people, remembers daily routine, executes requests without cues, complete unrelated tasks
  • Device

Cognitive Communication

• A&Ox ___
• Ability to express basic needs/ desires
• Follows ___ step commands
• Exhibition of safety awareness

Home Mgmt.

• ___SH with ____ steps to enter the home with/ without railing
• Family/ cg at home?
• Plans/ doesn’t plan to participate in home-mgmt skills upon d/c
  

DME

• Tub/ shower, rub seat, shower chair, grab bars, versa frame, w/c, FWW, ramp, SPC, reacher, sock aid, dressing stick

Strengths

• PLOF, active participant, good family support, cognition intact, owns equipment, good UE control, good UE strength, good standing balance, good sitting balance, vision intact, sensation intact

Weaknesses

• Precautions, PLOF, non-active participant, no family support, decreased cognition, doesn’t own DME, poor UE control, poor UE strength, poor sitting tolerance, poor standing balance, poor vision, poor sensation, decreased safety awareness, dysphagia, dysarthria, hemi-paresis

Routines/ Leisure Participation

Rehab Potential

• Good for OT goals

Assessment/ Summary

• _____y/o male/ female with ___(dx)____ & ____(precautions)__. Pt presents with (activity tolerance, pain level, balance, safety awareness). PLOF with BADLs and IADLs. CLOF with BADLs and functional xfers. Skilled OT is indicated for max safety and independence with BADLs and functional t/f’s prior to d/c ___(where)____.

LTG: (by d/c) pt will be _____ for BADLs, functional xfers, home management skills, and leisure participation with AE/AD/DME prn.

STGs: (in ___ weeks) pt will be (1) _____ for donning shirt using hemi-technique prn (2) ____ for SPT w/c><toilet with AD/DME prn (3) _____ for gathering ADL items from closet using AD/AE/DME prn (4) _____ for donning socks on BLE with sock-aid (5) _____ for donning shoes on BLE with LH shoe horn and LH reacher.

OT plan: ___x/week, ___x/day, ____ hours/ day for ADL re-training, strengthening/ ROM, coordination, endurance, balance, home mgmt., equipment request, functional mobility, pt education

OT d/c plan: home with family, LTC, ALF