Therapy note requirements:
- The authorization stamp of the organization with the signature of the occupational therapy nurse
- The date of the therapy (Lucas Molitor & Nissen, 2018)
- The time when the therapy ended
Social history and prior level of function:
Name: Scott Wilson
Date: 28/11/2019
Place: Home
Pain: Yes. Chest.
Able to dress, shower, cook on your own? : No.
Living in house? : Yes.
How many levels? Are there stairs? : Stairs are there. It is two levels.
What kind of bed do you sleep on? : He has a king size bed where he prefers to sleep.
Share your bathroom information: There are 4 bathrooms in the house. 2 on the ground floor and 2 on the top floor. It is not equipped with seats and railings because Scott believes they take away the charm of the house.
How is the kitchen setup? : The kitchen is set up in a modular way with everything accessible with ease.
Who cleans the house? : A part-time maid, Alexa comes to clean it.
Who lives with you? : Two Daughters who are 35 and 33 years old. They are married. No grandchildren.
Married (YES/NO): Yes.
Family lives nearby (YES/NO): No.
Who prepares food? : Scott and his wife, Amanda before the condition.
Who shops for grocery? : Amanda, Scott’s wife.
What are your hobbies? : Playing Basketball.
What do you enjoy doing? : Reading Books and watching sports.
ADL:
Chosen ADL: Sitting and Reading Books. This is important because he likes reading books and watching sports related to basketball (Prakash, Shah & Hariohm, 2016).
Devices: A walker, a comfortable Chair, A television and a magazine.
He is right-side paralyzed for which he has mood swings and feels depressed of not being able to play basketball. The first step that needs to be taken is making him walk with a walker as a support and make him sit in a chair such that he can watch television. Continuous sleeping can make his back ache and increases the risk of bed sore.
Other
- The medical history of the patient because of him being a basketball player. He has a chance of suffering from a concussion due to his sport which needs to be taken into consideration (Ozdemir et al., 2015).
- It is important to make sure that the bathroom contains necessary safety rails and seats such that it is easier for Scott to use them without the fear of slipping or sustaining a grave injury (Lutz et al., 2016).
- It is crucial to address the home condition of Scott and make sure they emotionally support him during this turmoil.
- His wife, Amanda should be informed about the dietary requirements and changes such that she can buy relevant grocery.
- It is critical to inform the family members residing with him to consider him not wearing socks as there is a chance that he may fall.
References
Lucas Molitor, W. M., & Nissen, R. (2018). Clinician, Educator, and Student Perceptions of Entry-level Academic Degree Requirements in Occupational Therapy Education. Journal of Occupational Therapy Education, 2(1), 2.
Lutz, B. J., Young, M. E., Creasy, K. R., Martz, C., Eisenbrandt, L., Brunny, J. N., & Cook, C. (2016). Improving stroke caregiver readiness for transition from inpatient rehabilitation to home. The Gerontologist, 57(5), 880-889.
Ozdemir, O., Giray, S., Arlier, Z., Baş, D. F., Inanc, Y., & Colak, E. (2015). Predictors of a good outcome after endovascular stroke treatment with stent retrievers. The Scientific World Journal, 2015.
Prakash, V., Shah, M. A., & Hariohm, K. (2016). Family’s presence associated with increased physical activity in patients with acute stroke: an observational study. Brazilian journal of physical therapy, (AHEAD), 0-0.
