Augusta Technical College

Occupational Therapy Assistant Program

Occupational Therapy Services
Daily treatment note
Date: July 31st 2015

Weekly summary

Discharge summary

Time: 7:30pm

S: Pt. states that he feels "good." Client was observed to be laughing and making
jokes.
At rest: 0 - 10
w/activity 0 - 10

Pain Scale:

Pain comments: Pt. states that he is very tight.

O: Pt. seen this date from: 1:00pm to: 2:00pm at: Clinical other:
ADL STATUS:
ADL

RATING

MEAL SET-UP:

MAX

EATING:

SBA

GROOMING

MOD

BATH/SHOWER

MAX

DRESSING UE
DRESSING LE
UNDRESSING UE
UNDRESSING LE
TOILETING

MAX
MAX
MAX
MAX
MAX

ADL TRANSFERS

MAX

BED MOBILITY

SBA

W/C MOBILITY

IND

WALKER MOBILITY

N/A

COGNITION: Purposeful-appropriate

COMMENTS
Pt. has 50% use of right UE and 80% use
of left UE due to contractures
Pt. can feed self mostly with left UE but
ROM is very limited
Pt. can reach and care for 85% of head
and UE
Pt. must be transerred and cannot reach
entire body due to contractures
Pt. can assist in dressing
Pt. can assist in dressing
Pt. can assist in dressing
Pt. can assist in dressing
Pt. must be transerred and needs
assistance to reach toilet care items
Pt. has sufficient strength to stand with
assistance for balance. Pt. is max assist
or mod x 2.
Patient can use UE and LE strength to
postion self lying down.
Pt. uses power wheelchair and navigates
easily.

Comments: pt. is alert and

appropriate in his response and
answers.

ORIENTATION: X4 (person/place/time/situation)

ATTENTION SPAN: Without Redirection

o
o

FOLLOWING COMMANDS: Follows_

3 -step commands
Cues required: pt. required cuing to keep his balance during EOB sitting.
General comments: Pt. performed EOB sitting for 4 min and 6min. Pt. was mod A
x2 <-> mat table. Pt. performed sit to stand 4 x, navigated different terrain in
power chair, reached to pick fruit, used nautilus machine to stretch UE with
grasp 8X 30 sec.

ADL deficits

Pain interfering with functional status

Cognitive/perceptual deficits impacting

independence/safety
UE function deficit interfering with functional status

Functional balance

Functional mobility

Functional communication

Functional problems

o
o

Due to
spasticity pt.
has limited use
of UEs
Due to
spacsticity pt.
has no standing
balance w/o
assistance

Pt.s voice is
raspy and quiet

Comments: Pt. tolerated EOB sitting with 4 cues to regain balance. When
positioning in powerchair pt. required extra time to position in his chair. Pt.
used left UE only to pick fruit. During nautilus training pt.s RUE lost grasp 3
times.

o
o

o Comments
Pt. is mod to
max assist on
ADLs

P: pt. to return July 3rd 2015 to address the following:

Comments: Pt. will return to OT to continue increasing strength and ROM for
increasing function such as EOB sitting while grooming, self feeding and
transferring.

o
o
o

Signature: James W. Brazelle, OTAS