General Information:
This client was evaluated on February 25, 2003 at ****** assisted living
facility.
Subjective:
�I didn�t even know I had a problem�
Objective:
Ambulated with rolling walker to bathroom with supervision,
approximately 50FT Able to raise/lower pants, with 1 verbal cue.
Assessment:
After extensive conversation with this client and with staff, it was
noted that the client is having difficulty with hygiene after
toileting. The client states that he is unaware of having any
problems with his hygiene. At this time, it is unclear as to the
primary cause(s) of the clients� issue. Staff reports helping the
client with hygiene secondary to his difficulty with appropriately
cleaning himself. He reports that he is able to care for himself
safely and independently.
Summary:
Client to be seen by OT for up to 3X/week for 4 weeks to improved
client�s independence with hygiene.
===========================================================================
> Hello:
>
> A while back, I THINK someone asked me to give an example of
> occupation-based practice. Today, I discharged a client and when writing the
> d/c note, I thought, this is an example of what OT means to me.
>
> I anticipate that I will present the case over a couple of e-mails.
> Hopefully, there will discussion among the list about the pros and cons of
> my treatment. Bear in mind that I only saw this patient twice, once for the
> eval and once for treatment. Even though the patient contact was very brief,
> I do believe it's a good example of occupation-based treatment.
>
> So, here it goes....
>
> I will call the client by a pseudonym: Charles.
>
> CLIENT DEMOGRAPHICS:
>
> Date of birth:
>
> 09/21/1925
>
> Primary diagnoses:
>
> Congestive heart failure
> History of CVA (stroke)
> Cirrhosis secondary to history of alcohol abuse
> Dementia secondary to CVA
>
> Currently living in an assisted living facility (ALF)
>
> Reason for referral:
>
> ALF staff reports that client is at times unable to adequately
> clean himself after bowel movements.
>
>
> Order requested and received for OT to Eval and Treat
>
> To be continued with results of initial evaluation....
_______________________________________________
To unsubscribe, visit: http://otnow.com/mailman/listinfo/otlist_otnow.com
The OTnow Mail Archive:
www.mail-archive.com/[EMAIL PROTECTED]
==============================================
