Ron 
We're overlapping responses the discussion is so hot and heavy. Your report
to the physician is great except for the last sentence. You said to me "the
patient and I opted to withhold treatment for one week and then reassess.
The patient feels her
situation is resolving on its own". 
Would you be comfortable replacing your last sentence to the doctor with
"After evaluation the patient and I opted to withhold treatment for one week
and then reassess. The patient feels her situation may resolve on its own."
This indicates that you did assist the patient to a level of comfort and
understanding of her own self efficacy. In other words you addressed her
occupational deficit to her satisfaction and satisfied yourself and the
doctor that she is not doing things to make her shoulders worse. "She
desires to forgoes therapy at the moment." feels like a cop out to me and
could be read as though you think he didn't need to make the referral.

Joan Riches
 

> -----Original Message-----
> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf
> Of Ron Carson
> Sent: Thursday, April 27, 2006 6:53 AM
> To: Joan Riches
> Subject: Re: [OTlist] Occupation
> 
> Joan,  I  don't really know what I meant by "not warranted". I shouldn't
> have said it!
> 
> You  asked many good questions, some of which I addressed in my eval and
> others I didn't. At the end of our eval, the patient and I opted to with
> hold  treatment  for  one  week and then reassess. The patient feels her
> situation  is resolving on its own and that therapy may not be indicated
> - I concur.
> 
> Honestly,  when  a  doctor  refers  a  patient  to therapy (OT or PT), I
> believe  they  are  expecting  the therapist to address the situation at
> hand.  In  this  case  the  referral was for rotator cuff problems and I
> believe that the doctors expects that therapy will address THAT problem.
> I  don't  really  think that U.S. doctors take time to even consider the
> various  problems that something like a rotator cuff injury might cause.
> They  are  medical  professionals  and they are trained to TREAT medical
> problems.  IF a doctor identifies a problem that he can not address, they
> they  refer  the  patient.
> 
> If  they identify a social problem, they might refer to a social worker,
> if  the  identified  a  mental  health  problem,  they  might refer to a
> psychiatrist.  If  they identified a musculoskeletal problem, they might
> refer  to  a  PT or OT if it's an upper extremity issue. And as you say,
> they  really don't identify ADL problems and I don't think they have any
> expectations  that  we  will  either.  Keep  in  mind that if you are in
> Canada, things may be a LOT different than in the U.S.
> 
> The  language of our profession is critical to binding it together. I do
> not  generally  talk  about occupation with my patients because doing so
> generally  leaves  them  with a glazed look. I address occupation in the
> majority  of  my goals, maybe even to a fault because I often don't make
> ROM,  strenght,  etc  my  goals.  For  example, if I treat the lady with
> rotator  cuff  injuries,  I  will  measure  her  ROM and I will probably
> include  it as a goal, but I will also include obtaining clothes as part
> of  her  goals.  Or, I might just skip over the ROM and only include the
> more  "functional"  stuff.  In fact, here's an excerpt from the doctor's
> report that I'm drafting:
> 
> quote> Patient  evaluated  at  her  ALF  residence. Patient complains of
> quote> decreased  bi-lateral  shoulder ROM and pain, but identifies pain
> quote> and limitations as being primarily in her right shoulder. Reports
> quote> difficulty  with  some  self-care.  Denies  any  difficulty using
> quote> rolling  walker  or  with sit to stand. She reports no history of
> quote> falls.  Patient  has  obvious limitation with bi-lateral shoulder
> quote> ROM..  She  has  difficulty  with  some  ADL's secondary to these
> quote> deficits. She desires to forgoes therapy at the moment.
> 
> I  don't  have  any  goals  because the patient is not being seen at the
> moment.
> 
> Joan,  what  I'm  looking  for  is  smoothness and consensus between our
> language  and  our  application.  At  the  moment, I don't think that it
> exists and for me, it's very frustrating and for the profession, I think
> it's very damaging.
> 
> Thanks,
> 
> Ron (not at all irritated) <smiling with you>
> 
> 
> ----- Original Message -----
> From: Joan Riches <[EMAIL PROTECTED]>
> Sent: Wednesday, April 26, 2006
> To:   [email protected] <[email protected]>
> Subj: [OTlist] Occupation
> 
> JR> What do you mean 'such recommendations are not warranted'? If they are
> JR> feasible even on a temporary basis, won't they help? Did you ask what
her
> JR> living situation was like? How did she damage her shoulders? Was it
repeated
> JR> strain over time, result of a fall, what? Is she short or tall? Is the
rod
> JR> in her closet actually too high for her? or is she trying to reach a
higher
> JR> shelf? Is a lower shelf available or feasible?
> JR> What is it she cannot reach on the table? Can you help her think about
her
> JR> living environment and how it might be adapted so she could manage
with less
> JR> pain? Does the culture of the Assisted Living Facility allow her to
ask for
> JR> help? Is she willing to do so or is she forcing her shoulders to show
she
> JR> can manage?  Is she cognitively able to understand consequences in the
> JR> future? Are there requirements for independent abilities to stay
there? Is
> JR> she afraid of transfer to Long Term Care? What do you think her
prognosis
> JR> for biomechanical recovery is? Depending on the injury sometimes older
> JR> people have to adapt to loss of range with rotator cuff injuries. Is
her
> JR> medication adequate for pain control? Is she taking it? Does she
understand
> JR> about maintaining a therapeutic level? Is there any reason to be
concerned
> JR> about the side effects of medication? Does she get up to go to the
bathroom
> JR> in the night? Is her way lighted?
> JR> I assume that when a doctor refers to OT it is because that is what is
> JR> expected. The reason OT is needed may be an injury but the physician
> expects
> JR> us to mitigate to the best of our ability and with all the resources
we can
> JR> muster the occupational effects of that injury. Of course they don't
refer
> JR> for difficulty in ADLs they don't assess for the practical
consequences of
> JR> injury but they certainly expect us to do so.
> JR>  Try to let go of your semantic preoccupation with occupation. Look at
> JR> people and ask yourself and them what they want, need or are expected
to do
> JR> and what you know that may help them. You'll find you are writing
notes
> JR> about restored occupation. (normal life - thanks Carmen)  Stop telling
> JR> yourself that there is nothing you can do that isn't PT and just do
it.
> JR> Joan (with some irritation)
> 
> >> -----Original Message-----
> >> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On
> Behalf
> >> Of Ron Carson
> >> Sent: Wednesday, April 26, 2006 8:21 PM
> >> To: Joan Riches
> >> Subject: Re: [OTlist] Occupation
> >>
> >> Hello Joan:
> >>
> >> It's funny how things sometimes fall into place. Just today, I
evaluated
> >> an  older  adult  living  in  an  ALF.  The  referral was secondary to
a
> >> doctor's  report  of  bilateral  rotator  cuff injuries. Notice that
the
> >> referral wasn't for difficulty bathing, eating, dressing, etc.
> >>
> >> Anyway,  in  talking  with  the client we identified obvious
limitations
> >> with ROM and she reported quite a bit of pain. BUT, she also stated
that
> >> she  had difficulty obtaining clothes from the closet and reaching
items
> >> on  the  dining  room  table.  So,  like  you  said, in listening to
the
> >> patient, she identified occupational deficits. But, here's the
confusing
> >> part.
> >>
> >> If  the  goal  is  occupation,  then  I  only  need  recommend  a
higher
> >> chair/lower  dining  table  and  that  she  place her clothes on a
lower
> >> shelf.  Thus,  her occupational performance is restored. Obviously,
such
> >> recommendations   are   not  warranted  but  isn't  this  what  you
are
> >> saying?
> >>
> >> Instead,  shouldn't  I  address the cause of her occupational
limitation
> >> which  of  course  are  biomechanical  in  nature.  But  addressing
her
> >> biomechanical problems so that she might better complete her
occupations
> >> is  no different than what a PT or in the case you gave, an RT might
do.
> >> They might not call them occupations but that isn't the point.
> >>
> >> It  seems  that looking at these situations kind of leaves OT stuck in
a
> >> vise.  We say we are about occupation but when the rubber hits the
road,
> >> we are only about occupation as an ancillary byproduct of our therapy.
> >>
> >> Ron
> >>
> >> ----- Original Message -----
> >> From: Joan Riches <[EMAIL PROTECTED]>
> >> Sent: Wednesday, April 26, 2006
> >> To:   [email protected] <[email protected]>
> >> Subj: [OTlist] Occupation
> >>
> >> JR> Do  you see your clients in their homes? Most people will tell
their
> >> JR> troubles  to  an  empathetic  listener  and even if the problem is
a
> >> JR> 'medical'  one  the  'troubles'  will  include  the  things they
are
> >> JR> prevented from doing.
> >>
> >>
> >>
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4/25/2006
> >>
> 
> 
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