Occupational Therapist-Vorlage
SAW Initial template
Eine professionelle Occupational Therapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a comprehensive occupational therapy assessment? This SAW Initial template is designed for occupational therapists to document a patient's injury, functional abilities, and plan for returning to work. It covers injury details, current physical tolerances, and pre-injury job tasks. This template helps therapists create detailed notes, including suitable work modifications and employer support. With Heidi, this template can be quickly populated from your visit transcript, saving you time and ensuring thorough documentation for your patients. This template is perfect for occupational therapists looking for a structured approach to patient assessment and return-to-work planning.
Vorlagenvorschau
Summary of injury and treatment
Patient sustained a right shoulder rotator cuff tear on 15 October 2024 during a fall at work. Underwent arthroscopic repair on 20 October 2024. Currently in a sling and participating in physiotherapy.
Current functional tolerances
Patient is currently unable to lift more than 5 pounds with the right arm. Limited range of motion in the right shoulder. Able to perform light activities of daily living with modifications.
Upcoming medical appointments
Follow-up appointment with Dr. Smith on 15 November 2024. Physiotherapy sessions twice a week.
Current medical certificate
Patient is currently signed off work until 1 December 2024. Restrictions include no lifting, pushing, or pulling with the right arm.
Pre-injury role title
Warehouse worker.
Normal working hours/days
Monday to Friday, 8:00 AM to 4:00 PM.
Work tasks
Loading and unloading trucks, moving packages, operating a forklift.
Physical requirements of tasks
Frequent lifting of up to 50 pounds, repetitive arm movements, prolonged standing.
Suitable work tasks for gradual return to work
Light administrative duties, such as data entry and phone calls. Modified tasks involving minimal use of the right arm.
Employer concerns and support of programme, barriers or opportunities
Employer is supportive of a gradual return to work. They are willing to provide modified duties and workplace accommodations. No barriers identified at this time.
Medications:
* Ibuprofen 400mg, as needed for pain
* Paracetamol 500mg, as needed for pain
Allergies:
* No known drug allergies.
Review of systems:
* Musculoskeletal: Right shoulder pain, stiffness, and limited range of motion.
Physical examination findings:
* Vitals: BP 120/80, HR 72, RR 16, Temp 37°C
* Right shoulder: Swelling and bruising present. Limited active and passive range of motion. Pain on palpation.
Assessment and differential diagnosis:
* Right shoulder rotator cuff tear, post-operative.
Plan of care:
* Continue physiotherapy twice a week.
* Home exercise program as prescribed by physiotherapist.
* Follow-up with Dr. Smith on 15 November 2024.
* Occupational therapy to assess functional capacity and facilitate a safe return to work.
* Review of work duties and potential modifications.
* Date: 1 November 2024
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