Professional Documents
Culture Documents
O: The client was seen for skilled occupational therapy services 1x/week for 1 hour
in the Life Skills Clinic or in his home a total of 8 times as part of the community
managing ataxia, and improving his insight and awareness for increased safety and
education, ADL training, and therapeutic activities. The client was educated on
positioning for safety, body awareness, and signs of fatigue. The client explored
outdoors, walks around the neighborhood, sports, music, books on tape, and social
media.
At discharge, the client demonstrates the ability to don and doff UB clothing, shoes,
shirt. He performs stand pivot transfers with min A for safety and positioning. He is
able to sit unsupported for 40 minutes with CGA. He requires mod verbal cueing for
(max A to min A), transfers (mod A to min A), sitting balance (max A to CGA),
postural endurance (15 min to 40 min), fine motor coordination and manipulation
(max A to I fastening pants), and use of his R UE (7 verbal cues to 1 verbal cue). He
continues to require cueing for posture, positioning, and fatigue awareness due to
poor body awareness, trunk strength, and trunk endurance. He requires extra time
and assistance with ADL tasks and transfers due to B UE ataxia, R hemiplegia, poor
motor control, and impaired balance and trunk stability. Areas of interest and
provides may or may not be accurate. B UE ataxia, R hemiplegia, poor motor control
and fine motor coordination, impaired balance and trunk stability, poor body
P: The client has met his goals and will be discharged from student services. He will
be referred to Heather Arias, OT, at the Life Skills Clinic for additional skilled
will continue receiving assistance from his home health aide 3 days/week. The
client requires new bed canes that can be safely attached to his bed.
Shayna Roberts 4/13/2017