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The OT Process Worksheet for Case study: Telephone Repairman Spinal Cord Injury C6
PROCESS STEPS
1 Referral
2 Screening
3 Evaluations
Functional problem list:
Acute Care
Eating, Dressing and Bed
Positioning are difficult to
perform due to lack of
wrist and hand function,
poor endurance and UE
strength.
STANDARDIZED:
NON-STANDARDIZED:
FOR/MOP APPROPRIATE
FOR DX:
Biomechanical
(remedial/restorative)
Rehabilitative Treatment
Approach
MOHO
Tx/intervention
Implementation
ACTIVE OCCUPATIONS:
- Feeding
- Bladder and bowel
- Don/Doff of clothing on
the UE and LE.
management
- Dressing
- Personal hygiene
- Functional mobility
- Eating a meal
- Playing a board game
- Petting and brushing his
dog
AROM exercises.
- Strengthening exercises
for upper extremities
Reevaluation Methods
Discharge Planning
(typical locations your
patients may be
discharged to)
Comments:
dog
Barthel Index (Functional Eval)
Sollerman Hand Test (Grip function)
Functional Independence Measure (FIM)
Client will be discharged to Inpatient subacute rehab, outpatient rehab, or home
health depending on clients progress and support. A home modification evaluation
is also recommended.