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Occupational Therapy Specialist
25-30 minutes

Initial NDIS Template

The NDIS Initial template by s10.ai is an all-encompassing documentation resource tailored for occupational therapists to evaluate and record the needs of individuals with disabilities. This template encompasses critical areas such as medical history, medication management, social supports, education, cognition, communication, mobility, and daily living activities. It is especially beneficial for crafting detailed initial assessments for clients within the National Disability Insurance Scheme (NDIS). By integrating this template with s10.ai, clinicians can swiftly produce comprehensive reports that facilitate the creation of personalized care plans and interventions, ensuring the highest level of support for their clients.

4,220 uses
4.8/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Identified Disabilities, Additional Conditions & Current Health:
- [Describe past medical history and previous surgeries]
- [Describe current issues, and history of presenting complaints]
- [Describe mental health status, history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention present and past substance use, drug and alcohol] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention hospitalisations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Medication Management:
- [Mention medications]
- [Describe management of medication, administration, storage and prescription]
Social History and Supports:
- [Mention who they live with]
- [Mention who their supports are, how much support they receive from them, and frequency]
- [Describe social deficits, ability to form relationships, ability to interpret social cues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention forensics history, incarceration, legal proceedings, community restrictions, parole] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Education and Employment:
- [Mention education history]
- [Mention employment history]
Cognition:
- [Describe cognitive function]
- [Describe orientation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe recall] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe memory] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe visuospatial skills] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe attention, concentration, focus] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe recognition skills] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Communication:
- [Describe communication abilities]
Behaviour:
- [Describe any behaviours of concern] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe type of behaviour, trigger, duration, frequency] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe mood and affect. Irritability, motivation, stability, insight or fluctuating mood, how client's mood influences participation and congruence of affect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe current strategies utilised to manage behaviours] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Sensation and Sensory:
- [Describe vision or sight] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe sense of touch] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe hearing] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe sense of taste] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe sense of smell] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe body awareness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe sensory function or concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention hallucations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Mobility:
- [Describe mobility function indoors, use of assistive technology, assistance required to mobilise]
- [Describe mobility function outdoors, use of assistive technology, assistance required to mobilise]
- [Describe balance and coordination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe falls history and falls risks]
- [Describe fine motor skills, hand function, and hand dominance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe range of movement] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe pain] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Transfers:
- [Describe bed transfers, and use of assistive technology]
- [Describe chair transfers, and use of assistive technology]
- [Describe shower or bath transfers, and use of assistive technology]
- [Describe toilet transfers]
- [Describe car transfers]
Pressure Management:
- [Mention history of pressure injuries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe skin integrity and risk of pressure injuries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Personal Activities of Daily Living:
- [Describe showering or bathing abilities, use of assistive technology, assistance required to shower or bathe]
- [Describe dressing abilities, use of assistive technology, assistance required to get dressed]
- [Describe toileting abilities, use of assistive technology, assistance required to toilet]
- [Describe issues with incontinence or continence] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe grooming abilities, use of assistive technology, assistance required to cut nails, brush hair, shave, brush teeth, apply make-up]
- [Describe feeding or eating abilities, use of assistive technology, assistance required to feed self or eat]
- [Describe sleeping habits, including quality, quantity and patterns, use of assistive technology, assistance required for sleep]
- [Describe intimacy or sexual activity] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention motivation to engage in personal activities of daily living, assistance required to engage] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Instrumental Activities of Daily Living:
- [Describe meal planning abilities, use of assistive technology, assistance required for meal planning]
- [Describe meal preparation or cooking abilities, use of assistive technology, assistance required for meal preparation or cooking]
- [Describe grocery shopping abilities, use of assistive technology, assistance required for grocery shopping]
- [Describe laundry abilities, use of assistive technology, assistance required for laundry tasks]
- [Describe domestic cleaning, use of assistive technology, assistance required for cleaning]
- [Describe external home or garden maintenance abilities, use of assistive technology, assistance required for external home or garden maintenance]
- [Describe child care abilities, assistance required to care for children] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe financial and health management abilities, use of assistive technology, assistance required to manage finances and health]
- [Describe community access abilities, use of assistive technology, assistance required to access the community]
- [Mention use of private or public transport] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention preferred leisure activities, use of assistive technology, assistance required to participate in leisure activities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention motivation to engage in instrumental activities of daily living, assistance required to engage] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Home Environment:
- [Mention type of accommodation]
- [Mention ownership of accommodation]
- [Mention home composition, number of bedrooms and bathrooms]
- [Describe front and rear access of the home] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention internal level change or stairs in the home] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe living area, use of assistive technology, environment, assistance required to access living area]
- [Describe bedroom area, use of assistive technology, environment, assistance required to access bedroom area]
- [Describe bathroom and toilet area, use of assistive technology, environment, assistance required to access bathroom and toilet area]
- [Describe kitchen area, use of assistive technology, environment, assistance required to access kitchen area]
- [Describe outdoor or garden area, use of assistive technology, equipment, assistance required to access outdoor or garden area] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Other:
- [Mention any other considerations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention cultural considerations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Goals:
- [Mention client's goals for therapy] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention occupational therapy recommendations or areas of priority] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe proposed intervention plan, frequency and duration of therapy] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention referrals to other services] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
(Never come up with your own patient history or details, assessment, diagnosis, plan, interventions, evaluation, explanation and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
Sample Clinical Note

Example of completed documentation using this template

Recognised Disability, Other Conditions & Current Health:
- The patient has a history of cerebral palsy and underwent scoliosis corrective surgery at age 12.
- Currently, the patient experiences muscle stiffness and challenges with fine motor skills, which have been present since childhood.
- The patient maintains stable mental health with no history of psychiatric disorders.
- The patient has no history of substance use, drug, or alcohol abuse.
- The patient has not been hospitalized in the past five years.
Medication Management:
- The patient is prescribed Baclofen for muscle spasticity.
- Medication is taken orally, stored securely, and prescriptions are managed by the primary care physician.
Social History and Supports:
- The patient resides with their parents.
- The patient receives daily support from family members and attends a community support group weekly.
- The patient has no forensic history or legal proceedings.
Education and Employment:
- The patient completed high school with special education support.
- The patient is currently unemployed but volunteers at a local community center.
Cognition:
- The patient exhibits average cognitive function with no significant deficits.
Communication:
- The patient communicates effectively using both verbal and non-verbal cues.
Mobility:
- Indoors, the patient uses a walker and requires minimal assistance.
- Outdoors, the patient uses a wheelchair and requires assistance for longer distances.
- The patient has a history of falls, primarily due to muscle weakness.
Transfers:
- The patient requires assistance for bed transfers using a transfer board.
- Chair transfers are performed independently with the use of a grab bar.
- The patient requires assistance for shower transfers using a shower chair.
- Toilet transfers are performed independently with the use of a raised toilet seat.
- Car transfers require assistance from a caregiver.
Personal Activities of Daily Living:
- The patient requires assistance for showering and uses a handheld showerhead.
- Dressing is performed independently with the use of adaptive clothing.
- The patient requires assistance for grooming tasks such as brushing hair and teeth.
- The patient feeds themselves independently but uses adaptive utensils.
- The patient has a regular sleep pattern and uses a body pillow for support.
Instrumental Activities of Daily Living:
- The patient requires assistance for meal planning and uses a meal delivery service.
- Meal preparation is performed with assistance from family members.
- The patient requires assistance for grocery shopping and uses a shopping list app.
- Laundry tasks are performed with assistance from family members.
- The patient requires assistance for domestic cleaning tasks.
- The patient manages finances with assistance from a family member.
Home Environment:
- The patient lives in a single-story home owned by their parents.
- The home has three bedrooms and two bathrooms.
- The living area is accessible with the use of a walker.
- The bedroom area is accessible with the use of a walker.
- The bathroom and toilet area are accessible with the use of grab bars.
- The kitchen area is accessible with the use of a walker.
Goals:
- The patient's goal is to enhance independence in daily living activities.
- Occupational therapy recommendations include increasing participation in community activities.
- The proposed intervention plan includes weekly therapy sessions for six months.
- Referrals to a physiotherapist for additional support have been made.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "Recognised Disability, Other Conditions & Current Health" clinical template is an essential tool for healthcare professionals seeking to streamline patient assessments and documentation. This comprehensive template allows clinicians to efficiently capture detailed patient histories, including past medical conditions, surgical history, and current health issues. It also facilitates the management of medication, social history, cognitive function, and communication abilities. By incorporating high-search healthcare keywords, this template enhances the accuracy and completeness of patient records, ensuring that all relevant aspects of a patient's health and lifestyle are meticulously documented. Clinicians can explore and implement this template to improve patient care, optimize workflow, and ensure compliance with healthcare standards. Adopting this template can lead to more informed clinical decisions and better patient outcomes, making it an invaluable resource in any medical practice.
Frequently Asked Questions

Common questions about this template and its usage

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