Download EvalTxPlanAdultTemplate

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
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OCCUPATIONAL ANALYSIS:
Occupations
Not
Dependent
ADL & IADL
Tested
Bathing/Shower
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Toileting
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Eating
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Feeding
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Dressing
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Functional
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Mobility
Max
Assist
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Mod
Assist
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Min
Assist
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Equipment Independent
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Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson.
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Grooming
Safety
Handwriting
Meal Prep &
clean up
Shopping
Laundry
Computer use
Phone use
Financial
management
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Communication
Light
housework
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Heavy
housework
Yard work
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Care of others
Child Rearing
Pet care
Shopping
Safety
Procedures
Emergency
Responses
Community
Mobility
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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
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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)
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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
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Absent
Impaired
Adequate
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Comments:
Modified from: Sames, K. (2015) Documenting Occupational Therapy Practice (3 rd Ed.). Boston, MA: Pearson.
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Bilateral integration
Other (describe)
Body
Structure
Eyes, Ears
Voice
Movement
Other
Deformity
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Movement
Limitation
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Normal
Comments:
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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
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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.