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Occupational Therapy Specialist
15-20 minutes

Occupational Therapy Evaluation and Suggestions

The s10.ai Occupational Therapist Summary/Recommendations template is expertly crafted for occupational therapists to meticulously document comprehensive client assessments. This template encompasses critical areas such as social circumstances, medical conditions, mobility, personal care, domestic and community activities of daily living (ADLs), cognitive function, and primary concerns. It also features dedicated sections for occupational therapy recommendations and a detailed action plan. Designed to facilitate the creation of thorough and organized clinical notes, this template ensures that every pertinent aspect of a client's daily functioning and needs is thoroughly addressed. Ideal for occupational therapists seeking a structured approach to documenting assessments and therapeutic plans, this template is an essential tool for enhancing clinical efficiency and patient care.

2,451 uses
4.4/5.0
A
alexander chen
Template Structure

Organized sections for comprehensive clinical documentation

OVERVIEW:
[Concise summary of essential points from the evaluation]
SOCIAL:
- [Current living arrangement]
- [Support from family]
- [Engagement with community]
MEDICAL:
- [Significant medical issues]
AMBULATION:
- [Assistive devices utilized]
- [Observations on gait and balance]
- [History of falls]
- [Implemented safety precautions]
PERSONAL CARE ADL:
- [Independence level in bathing and dressing]
- [Toileting capabilities and issues]
DOMESTIC ADL:
- [Skills in meal preparation and housekeeping]
- [Client's proficiency in these tasks]
COMMUNITY ADL:
- [Driving capabilities]
- [Management of transportation and appointments]
COGNITION:
- [Cognitive and memory status]
- [Capability to remain alone]
- [Need for assistance with activities]
PRIMARY CONCERNS:
1. [Concern 1]
2. [Concern 2]
3. [Concern 3]
4. [Concern 4]
OT SUGGESTIONS:
1. Equipment:
- [Suggested equipment 1]
- [Suggested equipment 2]
- [Suggested equipment 3]
2. Home modifications:
- [Suggested modification 1]
- [Suggested modification 2]
- [Suggested modification 3]
[Further notes on the home setting and current equipment/modifications]
[Client's approval for referrals]
PLAN:
1. [Task 1]
2. [Task 2]
3. [Task 3]
[Therapist Name(s)]
Occupational Therapist(s)
Sample Clinical Note

Example of completed documentation using this template

Mr. John Doe is a 78-year-old male with a history of Parkinson's disease and arthritis. He lives alone and has limited family support.
SOCIAL: 
- Resides alone in a single-story home
- Limited family support, occasional visits from a neighbor
- No active community involvement
MEDICAL: 
- Parkinson's disease
- Arthritis
AMBULATION: 
- Utilizes a walker for mobility
- Gait is unsteady with noticeable shuffling
- History of two falls in the past six months
- Safety measures include grab bars in the bathroom and non-slip mats
PERSONAL CARE ADL: 
- Needs assistance with showering and dressing
- Independent with toileting but requires supervision for safety
DOMESTIC ADL: 
- Has difficulty with meal preparation and housework
- Can manage light tasks but needs help with heavier chores
COMMUNITY ADL: 
- No longer drives
- Depends on a neighbor for transportation to appointments
COGNITION: 
- Mild cognitive impairment, forgets recent events
- Cannot be left alone for extended periods
- Requires assistance with medication management and scheduling
MAIN CONCERNS:
1. Risk of falls
2. Difficulty with personal care
3. Limited family support
4. Cognitive decline
OT RECOMMENDATIONS:
1. Equipment:
   - Shower chair
   - Raised toilet seat
   - Medication organizer
2. Home modifications:
   - Install additional grab bars in the bathroom
   - Improve lighting in hallways
   - Remove tripping hazards like loose rugs
Additional observations about the home environment and existing equipment/modifications: The home is generally safe but could benefit from additional lighting and removal of tripping hazards.
Client's consent to referrals: Client consents to referrals for home health aide and physical therapy.
PLAN:
1. Arrange for a home health aide to assist with personal care
2. Schedule a follow-up visit in one month
3. Coordinate with physical therapy for gait training and balance exercises
s10.ai
Occupational Therapist
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the assessment and documentation process for occupational therapists, ensuring a thorough evaluation of a patient's social, medical, and functional status. By incorporating high-search healthcare keywords, this template covers essential areas such as living situation, family support, and community involvement, alongside detailed medical conditions and mobility assessments. It evaluates personal care and domestic activities of daily living (ADL), providing insights into the patient's independence in showering, dressing, and meal preparation. The template also addresses community ADL, including driving status and transportation management, while assessing cognitive function and memory. Main concerns are clearly outlined, with occupational therapy recommendations for equipment and home modifications to enhance patient safety and independence. The plan section ensures actionable steps are in place, supported by the therapist's expertise. This template is an invaluable tool for clinicians seeking to adopt a structured, efficient approach to patient care, encouraging exploration and implementation for improved clinical outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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Occupational Therapy Evaluation and Suggestions