What you conjecture regarding the status of the client (e.g., the client appears fearful to be discharged from occupational therapy, the client reports she would like to continue with crocheting,

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What you conjecture regarding the status of the client (e.g., the client appears fearful to be discharged from occupational therapy, the client reports she would like to continue with crocheting,

Brief background on patient: Sadie is a 76 y.o woman with a history of bipolar disorder and OA. She wears glasses and other than that, her health has been stable and her mental illness controlled by medication. She is oriented to self, her environment and month, year, not exact date, if given cues. Sadie lives in an assisted facility with 4 other ladies. She receives all meals and laundry and housekeeping is done at the facility. The facility has a pet dog which Sadie and the other ladies help feed and take on walks with supervision. Sadie was independent with all her ADLs and ambulated without an assistive device prior to hospitalization. Her medications were provided to her. She participated in all the recreational activities provided such as Bingo, arts and craft, religious services, as well as going on supervised outings with the facility bus, when organized. Sadie likes to sew, knit and crochet. Sadie was found to be lethargic, not participating in the activities and not eating. Sadie was admitted to the hospital due to electrolyte imbalance and fainting. She was stabilized and transferred to the in-patient psychiatric unit due to acute exacerbation of depression. There she was evaluated by the interdisciplinary team, including the O.T and OTA. When stable, Sadie will be transferred back to the ALF.

GOALS, EVALUATION, DAILY PROGRESS, and DISCHARGE INFORMATION

GOALS

EVAL

10-25-17

10-27-17

10-31-17

11-02-17

11-04-17

D/C

11-07-17

1) Client will be independent using fork and spoon with no spillage for stabbing firm food items, and x1 spillage for mechanical soft food

Client required 5 physical prompts to use fork, and moderate spillage when scooping mechanical soft food. She is unable to stab firm food with a fork

Client required 3 physical prompts to use fork, and minimal spillage when scooping mechanical soft food

Client used fork for the first time, and was able to stab meat with 100% accuracy. When scooping eggs with fork, there was x3 spillage out of 5 attempts

Client was able to scoop eggs using fork with spillage x2. She ate the meat as if it was finger food, without prompts to use a utensil

Client used spoon with no spillage for oatmeal at breakfast

Client independently uses spoon for scooping with no spillage and can stab firm foods such as meat using a fork with a100% accuracy. She properly identifies which are finger foods and which are not.

Goal exceeded

2) Client will dress self in 15 minutes with no verbal cues or physical prompts

Client dresses in 35 minutes with 6 verbal cues and 4 physical prompts during the session

Client dressed in 25 minutes with 3 – 4 verbal cues during the session

Client dressed self in 21 minutes with 2 verbal cues, and 1 physical prompt

Client dressed in 21 minutes with only 1 verbal cue, and 1 physical prompt.

Client dressed in 19 minutes with 1 verbal cue and no physical prompts

Client dresses with modified independence for technique in 15 minutes with no verbal cues or physical prompts. Goal achieved

3) Client will attend a facility social activity, and participate x5 during a 30 minute session

Client refused to consider attending any social activities

Client would not attend a bingo game she was escorted to by aide

Client attended a bingo game, escorted by aide. She observed, and did not play

Client attended a current events group and participated x1 in 30 minutes.

Client attended a current events group and participated x 2 in 30 minutes

Client is attending bingo and current event social activities 2 -3x per week, and participates x4 during a 30 minute session. Goal nearly achieved

GOALS

EVAL

10-25-17

10-25-17

10-31-17

11-02-17

11-04-17

D/C

11-07-17

4) Client will identify at least 5 diversional activities she performed for play or leisure prior to facility admission

Unable to determine client’s interests/ diversional activities, prior to memory loss

Unable to determine client’s interests/ diversional activities, prior to memory loss

After x3 attempts with reminiscing cards, client indicated that she enjoyed fiber arts, reading magazines, cooking, walking outside, and grooming her dog

Goal Achieved

10-31-17

Goal Achieved

10-31-17

Client identified 5 diversional activities on 10-31-17 she performed prior to facility admission. Goal achieved

5) Client will independently perform at least 2 out of 5 diversional activities she identifies, 2 to 3x/per week

Refer to above #4

Not addressed this a.m.

Not addressed this a.m.

After orientation to library cart, client unable to recall library cart schedule after 5 minutes.

Client able to choose color of yarn for crocheting activity with only 1 verbal cue

Client demonstrated use of crochet needle provided by therapist, with fair coordination

Client had crocheted 6 inches of a scarf. She reports her hands hurt after “a while”.

Discussed a program to crochet afghans for kids at a homeless shelter.

Client tracks library cart schedule on a calendar, and is reading magazines regularly.

She had begun crocheting an afghan for a child in a homeless shelter.

Client is participating in the ‘Dog Therapy’ program in the activities Department. Goal achieved

QUESTIONS

Subjective Section

1. What the client, family or nurse may have reported to you

2. What you conjecture regarding the status of the client (e.g., the client appears fearful to be discharged from occupational therapy, the client reports she would like to continue with crocheting, etc.)

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