So, you went in for an occupational therapy screening, huh? Well, fret not, because we’ve got you covered with this example Occupational Therapy Screening Report. From identifying your strengths and challenges to outlining the goals for your therapy, this report will give you a clear picture of what to expect. Whether you’re curious about the process or simply looking for some guidance, this report is your ticket to understanding occupational therapy on a whole new level.
Patient Information
Name
John Doe
Age
42
Gender
Male
Date of Birth
January 15, 1979
Contact Information
Phone: (123) 456-7890 Email: johndoe@email.com
Referral Information
Referral Source
Dr. Jane Smith, MD
Reason for Referral
Mr. Doe was referred for an occupational therapy evaluation due to difficulty performing activities of daily living after a recent car accident.
Date of Referral
April 10, 2021
Medical History
Primary Diagnosis
Whiplash injury and post-concussion syndrome.
Co-morbidities
None reported.
Medication List
- Ibuprofen 400mg, three times daily as needed for pain
- Acetaminophen 500mg, two times daily as needed for pain
Hospitalizations
John Doe was not hospitalized as a result of the car accident.
Surgeries
John Doe did not undergo any surgeries related to the car accident.
Occupational Profile
Personal Factors
Mr. Doe is right-hand dominant and has always been independent in his activities of daily living. He lives alone and is single, without any dependents. He holds a master’s degree in computer science and was employed as a software engineer prior to the accident.
Social Factors
Mr. Doe has a supportive network of friends and colleagues who have been assisting him since the accident. He has expressed concern about losing his independence and ability to perform his job.
Environmental Factors
Mr. Doe lives in a third-floor apartment without an elevator, which has been challenging for him during his recovery. His apartment is well-equipped with modern technology.
Activities of Daily Living
Mr. Doe has reported difficulty with bathing, dressing, and meal preparation since the car accident. He feels fatigued and experiences pain while performing these activities.
Instrumental Activities of Daily Living
Mr. Doe has difficulty using his computer, driving, and managing his finances independently since the accident.
Work History
Prior to the accident, Mr. Doe worked full-time as a software engineer for a leading technology company. He was highly skilled in coding, problem-solving, and collaborating with colleagues.
Leisure Activities
Mr. Doe enjoyed cycling and playing the guitar as his main leisure activities before the accident. He has been unable to engage in these activities since the accident due to pain and physical restrictions.
Assessment Tools Used
Standardized Assessments
- Barthel Index of Activities of Daily Living (ADL)
- Canadian Occupational Performance Measure (COPM)
Observations
- Observation of Mr. Doe’s performance during ADL tasks
Interviews
- Interview with Mr. Doe to gather information about his concerns, goals, and challenges
Functional Capacity Evaluations
- Assessment of Mr. Doe’s physical capacity and stamina for work-related tasks
Results
Strengths
- Good problem-solving and critical thinking skills
- Motivated to regain independence
- Supportive social network
Challenges
- Fatigue and pain impacting activities of daily living
- Difficulty performing work-related tasks
- Emotional distress and concern about the future
Performance Patterns
- Mr. Doe exhibited a consistent pattern of fatigue and pain during activities of daily living and work-related tasks.
Performance Skills
- Impaired physical endurance
- Decreased range of motion in the neck and right arm
- Difficulty with fine motor tasks
Occupational Performance
- Mr. Doe’s ability to independently perform activities of daily living and work-related tasks has been significantly compromised due to his physical limitations and pain.
Recommendations
Interventions
- Provide pain management strategies and techniques
- Develop a gradual work reintegration plan
- Incorporate energy conservation and pacing strategies during daily activities
Adaptive Equipment
- Assess the need for assistive devices to promote independence in activities of daily living and work-related tasks
- Consider ergonomic modifications for Mr. Doe’s workstation
Modifications
- Recommend modifications to Mr. Doe’s apartment, such as installing grab bars in the bathroom and rearranging furniture for ease of movement
- Suggest modifications to his computer setup to reduce strain on his neck and right arm
Training and Education
- Provide education on proper body mechanics to prevent further injury and promote optimal performance during activities
- Offer training on energy conservation techniques to improve performance and reduce fatigue
Follow-up
- Schedule regular therapy sessions to monitor progress, adjust interventions as needed, and address any new challenges that may arise
Summary
Summary of Findings
Mr. Doe is a 42-year-old male who sustained a whiplash injury and post-concussion syndrome from a car accident. His primary challenges include pain, fatigue, and difficulty performing activities of daily living and work-related tasks. Despite these challenges, Mr. Doe demonstrates strengths in problem-solving skills and motivation to regain independence. Through standardized assessments, observations, interviews, and functional capacity evaluations, it was determined that Mr. Doe’s physical limitations and pain significantly impact his occupational performance.
Goals
- Improve Mr. Doe’s ability to independently perform activities of daily living
- Facilitate a successful return to work
- Reduce pain and increase physical endurance
Expected Outcomes
- Increased independence in activities of daily living
- Improved work-related performance and stamina
- Decreased pain and improved overall physical well-being
Additional Recommendations
- Collaboration with a rehabilitation counselor to address the emotional impact of the accident and assist with vocational planning
- Referral to a pain management specialist for further evaluation and treatment options
Signature
Occupational Therapist Name
Emily Adams, OTR/L
Date of Evaluation
April 25, 2021
Credentials
OTR/L
Disclaimer
Confidentiality
All personal and medical information provided in this report is considered confidential and will only be shared with relevant healthcare professionals and individuals involved in the patient’s care.
Limitations
This report is based on the information obtained during the evaluation and is subject to limitations such as the accuracy of self-report and external factors influencing performance.
Valid and Reliable Information
The assessment tools and techniques used in this evaluation are validated and widely accepted in the field of occupational therapy. The results and recommendations provided in this report are based on sound clinical judgment and evidence-based practice.
