5
COOKING Group Therapy Documentation Template SHORTCUT: /CG Subjective Patient consented to group therapy. Goals for session were reinforced to patient: 1. Standing balance/ tolerance training 2. bilateral hand tasks training Objectives Cognition: -Follows __ steps instructions consistently/inconsistently -Attention: Good/Fair/Poor -Sequencing: Good/Fair/Poor -Problem Solving: Good/Fair/Poor Social: -Patient was able/unable to initiate/ sustain appropriate conversation with other members -Maintains good/poor eye contact when talking -Mood: Physical: -Fine motor skills: -Bilateral hand use: -Sitting balance: -Standing balance: -Activity tolerance: ADLs: -functional mobility: -Transfers: Cooking group session: - able to hold ingredient with left hand and cut using right hand safely - able to stand over stove to cook fried rice with supervision - required physical facilitation to wipe utensils dry in standing -Safety Awareness: Good/Fair/Poor, able to handle knives and hot objects safely Intervention Cooking group (Mee Goreng) Evaluation (Dependent on goal that was referred for) Eg if for standing tolerance: - patient was able to sustain 10 minutes of standing activities. Required intermittent rest breaks during session. Form last revised JUNE 2015.

Group Documentation Template

Embed Size (px)

DESCRIPTION

OT documentation

Citation preview

COOKING Group Therapy Documentation TemplateSHORTCUT: /CGSubjectivePatient consente to !roup therapy"Goals #or session $ere rein#orce to patient: %" Stanin! &alance/ tolerance trainin!'" &ilateral han tas(s trainin!ObjectivesCognition:)*ollo$s ++ steps instructions consistently/inconsistently),ttention: Goo/*air/Poor)Se-uencin!: Goo/*air/Poor)Pro&lem Sol.in!: Goo/*air/PoorSocial:)Patient $as a&le/una&le to initiate/ sustain appropriate con.ersation $ith other mem&ers)/aintains !oo/poor eye contact $hen tal(in!)/oo:Physical:)*ine motor s(ills:)0ilateral han use:)Sittin! &alance:)Stanin! &alance:),cti.ity tolerance:,D1s:)#unctional mo&ility:)Trans#ers:Coo(in! !roup session:) a&le to hol in!reient $ith le#t han an cut usin! ri!ht han sa#ely) a&le to stan o.er sto.e to coo( #rie rice $ith super.ision) re-uire physical #acilitation to $ipe utensils ry in stanin!)Sa#ety ,$areness: Goo/*air/Poor2 a&le to hanle (ni.es an hot o&3ects sa#elyInterventionCoo(in! !roup 4/ee Goren!5 Evaluation4Depenent on !oal that $as re#erre #or56! i# #or stanin! tolerance: ) patient $as a&le to sustain %7 minutes o# stanin! acti.ities" Re-uire intermittent rest &rea(s urin! session"*orm last re.ise 8UN6 '7%9"CO// OUTING P1,NNING Group Therapy Documentation TemplateSHORTCUT: /COPSubjectivePatient consente to !roup therapy",ims o# session $as e:plaine to patient 4to prepare patient #or community outin!5ObjectivesCognition:)*ollo$s ++ steps instructions consistently/inconsistently),ttention: Goo/*air/Poor)Pro&lem Sol.in!: Goo/*air/PoorSocial:)Patient $as a&le/una&le to initiate/ sustain appropriate con.ersation $ith other mem&ers)/aintains !oo/poor eye contact $hen tal(in!)/oo:Physical:)Sittin! &alance:)Stanin! &alance:Community outin! plannin!:) a&le to set !oals #or sel# urin! comm outin!:%"'"- a&le to ienti#y possi&le pro&lems urin! comm outin!) re-uire prompts #rom therapist to ienti#y strate!ies to o.ercome pro&lemsInterventionCommunity outin! plannin!EvaluationParticipati.e" Tolerate $ell"*orm last re.ise 8UN6 '7%9"CO// OUTING Group Therapy Documentation TemplateSHORTCUT: /COSubjectivePatient consente to !roup therapy"Goals #or session $ere rein#orce to patient: %" Stanin! &alance/ tolerance trainin!'" Con;ence in communityObjectivesCognition:)*ollo$s ++ steps instructions consistently/inconsistently),ttention: Goo/*air/Poor)Se-uencin!: Goo/*air/Poor)Pro&lem Sol.in!: Goo/*air/PoorSocial:)Patient $as a&le/una&le to initiate/ sustain appropriate con.ersation $ith other mem&ers)/aintains !oo/poor eye contact $hen tal(in!)/oo:Physical:)*ine motor s(ills:)0ilateral han use:)Sittin! &alance:)Stanin! &alance:),cti.ity tolerance:Community outin!:- a&le to mana!e (er&s an stairs $ith super.ision/moi;e inepenence/ inepenently) money mana!ement: a&le to recei.e correct chan!e ) shoppin!: a&le to ma(e orer inepenently)Sa#ety ,$areness: Goo/*air/Poor2 a&le to loo( out #or oncomin! traEvaluation4Depenent on !oal that $as re#erre #or56! i# #or stanin! &alance:) Re-uire minimal assistance to &oar shuttle &us6! i# #or co!nition) Re-uire prompts to remem&er $hat to purchase*orm last re.ise 8UN6 '7%9"*,11S PR6?6NTION Group Therapy Documentation TemplateSHORTCUT: /*GSubjectivePatient consente to !roup therapy"Goals #or session $ere rein#orce to patient: %" 6ucate on #alls pre.ention techni-ues '" ObjectivesCognition:)*ollo$s ++ steps instructions consistently/inconsistently),ttention: Goo/*air/Poor)Se-uencin!: Goo/*air/Poor)Pro&lem Sol.in!: Goo/*air/PoorSocial:)Patient $as a&le/una&le to initiate/ sustain appropriate con.ersation $ith other mem&ers)/aintains !oo/poor eye contact $hen tal(in!)/oo:Physical:)*ine motor s(ills:)0ilateral han use:)Sittin! &alance:)Stanin! &alance:),cti.ity tolerance:*alls pre.ention !roup session:) a&le to ienti#y #alls &eha.iors inepenently) a&le to ienti#y en.ironmental ha@ars inepenently urin! simulate practice) re-uire .er&al prompts to recall #alls pre.ention strate!iesIntervention*alls pre.ention !roup therapyEvaluationParticipate $ell" *orm last re.ise 8UN6 '7%9"