CEBU VELEZ GENERAL HOSPITALDepartment of Rehabilitation Medicine

SECTION OF OCCUPATIONAL THERAPY

Name of Pt: ___________________________ OT-In-charge: __________________________Age/Sex: _____________________________ OT Supervisor: __________________________Diagnosis: ____________________________ Rehab Doctor in-charge: _________________Address: _____________________________ Date Referred: __________________________Contact No: __________________________ Date of Evaluation_______________________

ADULT INITIAL EVALUATION/RE-EVALUATION

S:

I. CHIEF COMPLAINT : (informant, should be verbatim)

II. HISTORY OF PRESENT ILLNESS: (indicate informant; state in chronological order, paragraph form)

When and how present condition started When / why / where was medical consultation made Medical intervention received Actions taken following medical consult- diagnostic procedures and results Indication of current medications (tabulated form) with schedule and

purpose – if taken regularly/irregularly i.e. Patient takes anti-hypertensive drugs regularly

OT prescription, also indicate if receiving other medical services like PT, ST, etc

Include functional (ADL) status after each episode / stages of recovery (in pt/out pt)

For RE: indicate pt’s attendance if he comes regularly or not, previous management given, improvements/regressions noted by the pt or caregiver, verbalizations regarding OT as well as if HIP is being carried out at home if not then state the reason

Precautions indicated by the MD (transfers, post-op wounds, hypertension, SOB, etc)

BP: usual: _________ mmHg

III. MEDICAL HISTORY Previous strokes/ TIA and residual deficits HTN especially if less than 60 y/o Cardiac diseases especially if pt is young or if embolic stroke DM Hypersensitivity reactions Presence of other conditions

Previous therapy (include type of therapy, frequency, management received, and changes noted in functional status)

IV. FAMILY MEDICAL HISTORY (as necessary; tabulated form)Maternal Paternal

HTNCardiopulmonary DiseasesHypersensitivity ReactionsDMArthritisOthers

V. SOCIAL HISTORY High salt, cholesterol diet Alcoholism Smoking

VI. CONTEXTS

A. Physical Context 1 or 2-storey house Any stairs / number of steps? Sufficient space for locomotion and wheelchair accessibility (at home or in

the community, as pertinent) Location and distance of rooms, especially of bedroom & bathroom,

organization fo the environment (at home or in the workplace, community, as pertinent)

Accessibility to rehab (how long does it take to go to rehab, mode of transportation)

Accessibility to resources in the community (if applicable) Other environmental barriers that may interfere occupational performance

(as necessary) i.e. flooring, type of wheelchair, bed rails)

B. Personal-Social Context Vocational History / Educational History including present roles (at home

or in the community, as pertinent) Civil status, number of children Primary caregiver; other forms of support including finances Pt’s and caregiver’s awareness of the condition, attitude towards

disability/therapy Pt’s and caregiver’s motivation towards OT; ability and willingness to carry

out home instructions

VII.GOAL: (informant, should be verbatim)

O:BP: a: _________ mmHg p: _________ mmHg

I. OCCUPATION-BASED EVALUATION

Note: If acquired through interview, please put at Subjective part after ContextsUse the Functional Independence Measure in evaluating ADL.

Pt has a total score of ___/128 and is dependent / modified independent in the ff. areas:

Item Score Description of Performance(if from caregiver or S.O., please put as indicated

by whom)

II. PERFORMANCE SKILLS, COMPONENTS AND CLIENT FACTORS

A. SENSORIMOTOR SKILLS, SENSORY AND NEUROMUSCULAR FUNCTIONS

I. ROM All joints of (state the side / extremity) are essentially WNL upon PROM.

Except for the ff:o State the joint, movement, the available ROM, and the cause of

LOM:e.g. (R) shoulder flexion – 0-80° 2° to pain

TEST FOR:SH flx/ext FA sup/pronSH horizontal add/abd wrist flx/ extSH IR/ER Radial/ ulnar deviationElbow flx/ext finger movements

II. MMT MUSCLE TONE OF (B) UE/LE

State whether flaccid, hypotonic, spastic (use Modified Ashworth Scale) or normotonic and indicate the muscle group affected

e.g. Grade 1+ spasticity of (R) elbow flexors

MUSCLE STRENGTH OF (B) UE/LE

Grade Definition0 Zero No ms contraction can be seen or felt1 Trace (T) Contraction can be observed or felt, but there is

no motion2- Poor

Minus(P-)Part moves through incomplete ROM with gravity minimized

2 Poor (P) Part moves through complete ROM with gravity minimized

2+ Poor Plus (P+)

Part moves less than 50% of available ROM against gravity or through complete ROM with gravity minimized against slight resistance

3- Fair Minus Part moves through more than 50% of available

(F-) ROM against gravity3 Fair (F) Part moves through complete ROM against gravity3+ Fair Plus (F+) Part moves through complete ROM against gravity

and slight resistance4 Good (G) Part moves through complete ROM against gravity

and moderate resistance5 Normal (N) Part moves through complete ROM against gravity

and maximal resistance

MUSCLE BULKNote any atrophy or hypertrophy (provide measurement as necessary)

III. OTHER PERTINENT FINDINGS(Include all possible findings related to the condition, starting with (+), then (-) findings) NGT Tracheostomy Facial asymmetry Shoulder subluxation (# of finger breadths) Edema Pathologic reflexes Hypertrophic scarring Use of any assistive device Contractures Assistive device Adaptive device Foot drop Inflammation Trophic changes Type of gait Other significant physical findings

IV. ANALYSIS OF UPPER LIMB FUNCTION Handedness _____

(Intact, impaired, absent) voluntary RGCR pattern – document your clinical observations using this table:

PRESENT

PRESENT

with DIFFICULTY

ABSENT

REMARKS

REACH L R L R L R Reach forward to pick up or

touch an object Reach sideways to pick up an

object Reach objects placed

overhead Reach objects with arm

stretched behind Reach objects placed across

midlineGRASP

Grasp with radial deviation and with wrist extension

Wrist in extension while holding an object

Thumb opposes while holding an object

Able to cup hand ]flexion and conjunct rotation (opposition) of individual fingers towards the thumb]

Picks up an object with appropriate pronation of the forearm

Picks up various small objects between thumb and fingers

CARRY Holds different objects while

moving armRELEASE

Extension of the MCP joints of the fingers with IP joints in some flexion

Release an object with neutral or some extension of the wrist

Prehension Patterns

o Grade the gross prehension patterns (cylindrical, spherical, hook); and fine prehension patterns (pad to pad, tip to tip, tripod, lateral) using the scoring system below. document your clinical observation per prehension pattern by indicating the criteria shown in the table above.

G Assume, maintain, AND useF Assume AND maintain BUT cannot / has difficulty usingP Assume OR maintain BUT with difficulty / needs assistA Cannot assume or maintain

Grip/ Pinch Strength o Measure the grip strength, pinch strength using the

dynamometer and pinch gauge based on normotive values.R Functional

JustificationL Functional

JustificationGrip Strength Pinch Strength

Tripod Lateral Pad to Pad

* Provide at least 2 FUNCTIONAL JUSTIFICATIONS (each) for grip and pinch strength

Dexterity and Coordinationo Measure coordination and dexterity by using standardized tests

(MRMT). Provide a summary of your results (score and observations)

o Include description of Writing skills (if applicable)

V.ASSESSMENT FOR BALANCE AND TOLERANCE BALANCE

TASKS Without

difficulty

With difficul

ty

REMARKS

Getting up from a chairSitting down on a chairReaching up to retrieve objects in sittingReaching up to retrieve objects in standingBending over to retrieve objects in sittingBending over to retrieve objects while in standingStatic standing while engaging in activityDynamic standing while engaging in activityCarrying objects in the distance of ____ feet

TOLERANCETIME OF

TOLERANCEGRADING REQUIREMENTS

SittingStandingWalking

NOTE:a. Get time of tolerance for the highest potential of patient (e.g. sitting

on stool)b. Requirements include: without support, with support, use of

adaptive/assistive devices, type of surface, standbox, standbox with PKS, tilt table

GRADING:

Good: above 30 minutesFair: 16-29 minutesPoor: 0-15 minutes

VI. SENSORY FUNCTIONS Generalized sensation

o Pt claims to have ____% intact sensation on (specify area)o Use the “%” system, based on px’s answer

Sensory functionsNOTE:1. In assessment of peripheral nerve dysfunction, use sensory distribution

of nerves that are affected. Provide a summary of results (score and observations) of the Semmes Weinstein Monofilament Test

2. In assessment of spinal cord injuries, use sensory distribution of the dermatomes. Provide a summary of results of the ASIA Sensory Examination

3. In assessment of other cases (e.g. CVD, TBI, MS, etc.) other than the abovementioned, perform a clinical assessment using anterior/posterior diagram:

a. Light touch / localizationb. Pressure sensationc. Superficial paind. Proprioception

TEST POSITIONS: index finger flexion, middle finger extension, thumb extension, little finger flexion, wrist flexion, wrist extensionRESPONSE: “up”, “down”, “out”, “in”SCORING:

Plus (+): if the direction is correctly perceivedMinus (-): if response is delayed or nearly correctZero (0): if the direction is not perceived

B. COGNITIVE AND PERCEPTUAL FUNCTIONSUse the following guidelines. NOTE: if perception is intact or present, you can indicate in paragraph form that certain disorder/s are absent or (-) then justify or indicate how it was tested. Use tabulated form.

Scoring Test JustificationIntact/Impaired/Absent/

(-/+)(describe or illustrate) (describe)

I. PERCEPTUAL SKILLS

1. Kinesthesia TEST: same as test for proprioceptionScoring:

Plus (+): if the correct response is givenMinus (-): if the response is delayed or nearly correctZero (0): if the response is obviously incorrect or if no response

is given

2. Motor-PerceptionScoring: (+/-)

a. Ideational apraxiab. Ideomotor apraxiac. Dressing apraxiad. Constructional apraxiae. Oral apraxiaf. Verbal apraxia

3. Body Scheme Perceptiona. Somatognosia

TEST: point to body parts on command or draw a human figureScoring: (include functional justifications for patient’s response)

(-): pt correctly indicates all parts named within a reasonable length of time(+): impaired: pt correctly indicates some but not all parts named; or severely impaired: is unable to indicate parts named

b. Unilateral neglectTEST: Draw a Man; Line bisection; Clinical observationScoring: (include functional justifications for patient’s response)

(-): drawings include all parts in proper places

(+): some parts are missing from the leftc. Finger Agnosia

TEST: finger localization, finger identification by name, imitationScoring: (include functional justifications for patient’s response)

(-): pt correctly indicates all fingers named and imitates movements respectively within a reasonable length of time(+): impaired: pt correctly indicates some but not all fingers named; patient correctly imitates some but not all movements; or severely impaired: is unable to indicate parts named and imitate movements

4. Visual Perceptiona. Visual Agnosia

TEST: identify common objects by sightScoring: (+/-)

5. Visual Spatial Perception a. Form Constancy

TEST: functional test – sorting task; present objects one at a time in various position and sizes and ask him to identify them

Scoring: intact/impaired (include justifications for patient’s response)

b. Position in spaceTEST: positioning blocksScoring: intact/impaired (include justifications for patient’s response)

c. Spatial RelationsTEST: copying block designScoring: intact/impaired (include justifications for patient’s response)

d. R/L Discrimination TEST: Point to body parts on commandScoring: (include justifications for patient’s response)

Intact: patient correctly indicates all parts named within a reasonable length of time

Impaired: patient correctly indicates some but not all parts named; or is unable to indicate parts named

e. Figure-ground discriminationTEST: distinguish a target object from the backgroundScoring: intact/impaired

f. Depth-perception/StereopsisTEST: place common objects in front of the patient at varied distances and ask patient to identify which is the nearest and farthestScoring: intact/impaired (include justifications for patient’s response)

6. Tactile Perception a. Stereognosis

TEST: identify common objects with vision occludedScoring: intact/impaired (include justifications for patient’s response)

II. COGNITIVE SKILLS

1. Orientation TEST: Q & A

Result

Oriented to:

Testing Procedure Response

(+/-) Person (Who am I?) (+/-) Place (Where am I?)(+/-) Time (What year, month,

day, or time is it?)

2. Attention (describe)E.g. Patient is alert, awake, can maintain focus as long as needed (you can specify for how long), and was able to shift focus when another event of interest or importance occurred (specify any changes made in reference to activity or an area in assessment)

3. Concentration (describe)E.g. Patient may be highly distractible or very sensitive to events in the immediate environment, which pulls his or her focus away from the task at hand; note the type of stimuli (visual, auditory, tactile, or gustatory) that distracts the patient easily.

4. MemoryResult

Memory Tasks

Testing Procedure

Presentation Response

(+/-) Immediate memory

E.g. Recall objects just shown within 60 seconds

(describe how it was actually

done)

(describe how client

responded)

Delayed Memory(+/-) Episodic

memoryE.g. Ask autobiographical information

(describe how it was actually

done)

(describe how client

responded)Memory Retrieval(+/-) Recognition E.g. Show

photos of faces then ask to recall

(describe how it was actually

done)

(describe how client

responded)

5. Problem-Solving Skills (describe how this was tested)Test: Situational

6. Abstract Thinking (describe how this was tested)Test: Situational

7. Calculation Abilities Test: successive interval subtraction of 5 or 7 starting 100.

8. Number Recognition

9. Simple to Complex MathematicsTest: calculating change, recognizing coins, and budgeting

C. COMMMMUNICATION SKILLS- Use the Communication part of the Functional Independence

Measure to assess for comprehension and expression. Do not include the numerical score but indicate the level of assistance and pertinent observations.

- Indicate clinical observations of aphasia, dysarthria, etc.- Indicate mode of communication (verbal, gestures, writing, etc., as

pertinent)

A:

Integrate the results of your evaluation by:a. Identifying the pt’s strengths and weaknesses in a tabular form:

STRENGTHS WEAKNESSES

b. Stating your hypothesized prognosis in play, self-help and school participation based from your findings noted during the interview, clinical evaluation, and medical prognosis (according to literature).

o Pt has (good/guarded/poor) prognosis in (area) (performance, skills, and contexts)

c. Determining your OT problem list by assessing which activity demands, contexts, performance skill deficits, missing performance components or client factors are limiting occupational performance

OT PROBLEM LIST1. Pt has difficulty in (Performance Area) secondary to (which activity

demands, contexts, performance skill deficits, missing performance components or client factors are limiting occupational performance) associated with / secondary to (MEDICAL DIAGNOSIS)

P:1. PROBLEM

LTGThe acceptable form: To improve (AREA):

STG 1:Patient will be able to (description of specific steps of the functional activity expected of the patient) given (conditions/criteria, such as level of independence, materials/equipment to be used, etc) after (# of sessions).

POA:TUA:

o Preparatoryo Purposefulo Occupation-bsed

RECOMMENDATIONS:

Prepared by: Noted by:_________________ ______________OT-in-charge OT Clinical Supervisor