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OCCUPATIONAL THERAPY EVALUATION & INTERVENTION REPORT Adult/Adolescent BACKGROUND INFORMATION Date of Report: Client’s name or initials: Date of Birth or Age: Date of Referral: Primary intervention diagnosis/Concerns: Secondary diagnoses/concerns: Reason for referral to an OT: Therapist(s): Assessments performed (Check those used): ❑ ADL Observation ❑ Berg Balance Scale (BBS) ❑ Cognitive Performance Test (CPT) ❑ Fall Risk Assessment ❑ Jebson Hand Function Test ❑ Motor Free Visual Perception Test Revised (MFVPT-R) ❑ Patient Interview ❑ Routine Task Inventory ❑ Stroke Impact Scale ❑ 9-hole Peg Test ❑ Other: ❑ Allen Cognitive Level (ACL) ❑ Canadian Occupational Performance Measure (COPM) ❑ Ergonomic Assessment ❑ Functional Capacity Testing ❑ Manual Muscle Test ❑ Occupational Performance History Interview-Second Version (OPHI-II) ❑ Role Checklist ❑ Sensory testing ❑ Timed Get Up and Go Test ❑ AM-PAC ❑ Cognitive Assessment of Minnesota (CAM) ❑ Executive Function Performance Test (EFPT) ❑ IADL Observation ❑ Modified Barthel Index ❑ Neurobehavioral Cognitive Status Screening Examination (COGNISTAT) ❑ ROM ❑ Short Blessed Test ❑ Wolf Motor Function Test FINDINGS Occupational Profile Summary: EDUCATION (includes activities needed for learning): WORK (Employment interests, current job, job performance, volunteer exploration): LEISURE (Interests, exploration, participation) SOCIAL PARTICIPATION (Community, Family, Peers, Friends) CONTEXTS and ENVIRONMENTS: CURRENT LIVING ENVIRONMENT: another’s home (# of stories _____) own home ( # of stories ____) other (describe) rental home or apartment ( # of stories ____) RESIDES WITH: � alone � spouse �family � siblings� other (extended family/friends) Describe ARE ANY ENVIRONMENTAL MODIFICATIONS/EQUIPMENT NEEDED: �YES �NO If you checked yes, please describe the modifications Equipment Alarms: if equipment alarms are activated, are they sufficiently audible with respect to distance &background noises? �N/A �Yes �No Comments: Safety Concerns for the environment: �transitional housing �privacy needs �access to bathing facilities �clutter �inadequate lighting �access to kitchen/cooking facilities �other safety issues OTHER ENVIRONMENTS/CONTEXTUAL CONSIDERATIONS: (describe other environments & contextual considerations that are relevant to patient’s occupational performance & patient’s/caregiver’s concerns related to those environments). Specific test results (Include a brief description of each assessment tool with scored data): Name of Test Raw Standard Percentile Age Comments: (subtest) Score Score Rank Equivalent OCCUPATIONAL ANALYSIS: Occupations Not Dependent ADL & IADL Tested Bathing/Shower Toileting Eating Feeding Dressing Functional Mobility Max Assist Mod Assist Min Assist Equipment Independent Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson. Grooming Safety Handwriting Meal Prep & clean up Shopping Laundry Computer use Phone use Financial management Communication Light housework Heavy housework Yard work Care of others Child Rearing Pet care Shopping Safety Procedures Emergency Responses Community Mobility Describe areas of concern: Performance Skills (Does client have any challenges in these abilities when performing actions?) Skill Not Tested Absent Developing Proficient Comments: Posture Balance Fine Motor Coordination Gross Motor Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson. Coordination Visual Motor Coordination Following Directions Sensory Processing Emotional Regulation Cognitive Skills Communication & Social Skills Other (describe) Performance patterns (Describe the client’s habits, roles, routines) Useful Habits Routines Impoverished/Dominating habits Roles Rituals Client Factors In comments section: Specify and describe the deficits that restrict/impede performance. Body Functions Motor Sensory Specific Mental Attention Memory Sequencing Initiative Distractibility Sight Hearing Smell Taste Touch Vestibular Kinesthetic/Proprioceptio n Temperature Pain Muscle Tone Motor Reflexes Endurance Joint Stability & mobility Praxis Not Tested Absent Impaired Adequate Comments: Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson. Bilateral integration Other (describe) Body Structure Eyes, Ears Voice Movement Other Deformity Movement Limitation Normal Comments: R R L L B B Describe:________________________________________________________________ INTERPRETATION (Summary of all information) Strengths and areas in need of intervention: Supports and hindrances to occupational performance Prioritization of needs areas: 1. 2. 3. PLAN: Mutually agreed upon longterm goal Mutually agreed upon shortterm goal Plans for Coordination/communication with school based team Intervention Methods/Approaches Phone Email Conference Frequency: At least _____X/ Month More often as needed Plans for Coordination/communication with family Phone Email Conference Frequency: At least _____X Month More often as needed Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson. Plans for Discharge and follow-up Phone Email Conference Frequency: At least _____X Month More often as needed Intervention will be provided ______X/week, ________min. sessions, for _____weeks at Clinic Home other __________________________ Anticipated D/C environment: School Home other __________________________ Signature (sign, give appropriate initials, and print name) Date Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson.