OT reason to cont:
3.Pt demonstrates potential for further functional progression with respect to ADLs and required safe mobility.
1.OT to continue /c remediation of underlying performance component deficits that effect living skills
Pt continues to exhibit deficits in functional tasks lending to safety issues that should improve with continued tx
Pt continues to progress toward goal attainment.
2.Pt has made gains towards established short term goals but continues to display deficits of independence in dressing, transitions, and endurance. Patient could benefit from continued OT services to facilitate ease of self-care/ ADL'S.
4.Patient is progressing well towards therapy goals and would benefit from continue OT services to facilitate achievement of above mentioned goals
Patient has progressed well towards established goals and would benefit from continued skilled OT services to achieve standing tolerance, endurance, dressing, and reduce pain level for continued independence in functional abilities
OT to address remaining functional deficits noted and prep for d/c to home /c appropriate HEP
Patient could benefit from continued OT services to facilitate greater safety and ease of light household tasks, strength and endurance tolerance, and enhance compliance with compensatory strategies.
Pt making steady gains toward goals. Skilled OT continues to be indicated to advance to highest functional level with ADL and mobility tasks secondary to pt plans to return home.
To maximize function with transfers, ROM and ADL tasks.
Pt showing steady progress with increased activity tolerance, and ADL tasks.
Pt cont to perform daily tasks/ADLs /c considerable and taxing effort. Cont OT skilled intervention.
Patient could benefit from continued OT services to achieve above mentioned goals. Patient remains well motivated for therapy services
Pt has demonstrated significant progress in functional abilities as a result of skilled occupational therapy intervention. The gains made in the areas of upper extremity strength, functional activity tolerance, fine motor abilities, and static/dynamic balance have had a positive impact on the patient’s ability to perform basic self care as well as greatly improved patient’s safety while engaging in these tasks. While overall function has increased the patient continues to demonstrate deficits that hinder maximum independence with self care and would benefit from continued skilled occupational therapy treatment.
---D/C:
Pt exhibits good carryover of all set goals and is ready to be d/c’d from OT skilled services. Pt has shown remarkable improvement in all areas of stated goals. Pt will continue to be monitored by caregivers for ongoing and optimal success of all techniques and strategies pt has learned.
Pt has reached potential functional outcome /c stated goals.
Pt is being d/c'd from OT skilled intervention as pt has reached potential functional outcome /c stated goals. Pt has made good gains towards incr indep and ease in daily tasks has greatly improved. Staff to continue care accordingly for optimal success of all techniques pt has acquired.
Therapeutic ex/act, neuroreed, manual tx, and self care mgmt.
joint integrity --Isometrics B.shld to be utilized
Modailities PRN for jt stiffness and pain mgmt.
Meds:No precautions with regard to pharmacology has been communicated to this therapist.
PLOF: Pt resided in LTC facility and required assist for UB dsg and fastners /c FMC of Fair+; pt was able to tolerate functional tasks for 30 mnts, and demonstrated dynamic sit balance of Fair+; and UB str of 4+/5.
--EVAL:
Pt presents /c deficits in self care mgmt due to functional limitations and weakness. Pt fatigues easily during functional tasks and requires more assist to complete daily activites. ADLs require considerable and taxing effort.
Pt experiencing a decline in self care tasks and functional mobility. Pt presents /c apparent mx weakness in BUEs and trunk hindering pt from performing at the max potential.
Reason for Referral: Pt has had a recent hospital stay with a resulting decline in functional abilities the negatively impacts occupational performance. Pt at risk for skin breakdown, falls, and illnesses related to weakness and inability to perform transitional mvmts. Pt /c functional limitations, decr safety /c apparent decline in occupational performance due to deconditioning.
Pt has been a resident of this LTC facility and has recently experienced a decline in functional abilities.
Pt has been a resident of this LTC facility and has recently experienced a decline in functional abilities that has negatively affected occupational performance. Pt exhibits safety concerns due to unsteadiness and inadequate pacing/compensatory strategies. Decline apparent in functional status /c noted unsteadiness during ADLs and functional mobility.