OT Assessment Template

Occupational Therapy Assessment Template 1. Patient Information Name: John Smith Date of Birth: 12/03/1950 NHS / Hospital Number: 1234567890 Address / Contact: 10 Downing Street, London, SW1A 2AA Date of Assessment: 1 November 2024 Assessor: Dr. Jane Doe, Occupational Therapist Location (ward/community): Community setting --- 2. Referral Details Reason for Referral: Patient referred for assessment of functional abilities following a stroke. Date of Referral: 25 October 2024 Referrer (name & role): Dr. Alice Brown, GP Background Summary: The patient suffered a stroke two weeks ago and is experiencing weakness on his left side. He is currently at home with his wife. --- 3. Medical & Social History Primary Diagnosis: Cerebrovascular accident (stroke) Relevant Medical History: Hypertension, Hyperlipidemia Surgical History (if applicable): None Medications: Aspirin 75mg daily, Atorvastatin 20mg daily, Ramipril 2.5mg daily Social History: The patient is married and lives with his wife in a two-story house. He was previously employed as a teacher. He is a non-smoker and drinks alcohol occasionally. He has a supportive family and social network. Living situation: Lives with wife in a two-story house. Support network: Wife, two adult children. Employment / occupation: Retired teacher. Hobbies / interests: Reading, gardening. --- 4. Functional Assessment Personal care (washing, dressing): Assistance Toileting: Assistance Mobility: Assistance Transfers (bed, chair, toilet): Assistance Meal preparation / feeding: Assistance Domestic tasks: Assistance Community access: Assistance Communication: Independent --- 5. Cognitive / Perceptual Assessment Orientation (time/place/person): Oriented to person, place, and time. Attention / Concentration: Reduced attention span. Memory: Short-term memory deficits. Problem-solving: Impaired problem-solving abilities. Insight / Awareness: Aware of deficits. Perceptual difficulties (e.g., visual neglect, apraxia): No perceptual difficulties noted. --- 6. Physical Assessment Upper limb function: Weakness in left upper limb, reduced range of motion. Grip strength / fine motor control: Reduced grip strength on left side. Balance / postural control: Impaired balance. Endurance / fatigue: Reports fatigue with activities. Pain: No pain reported. Sensory issues: No sensory issues reported. --- 7. Environmental Assessment (if applicable) Access to property (steps, ramp, lift): Two steps at the front door. Layout / safety concerns: Cluttered environment. Equipment in situ: None. Recommendations: Recommend grab rails and a ramp. --- 8. Patient Goals Goal 1: To be able to dress independently. Goal 2: To be able to prepare a simple meal. Goal 3: To be able to walk to the local shop. --- 9. OT Recommendations / Plan Equipment provision: Recommend a raised toilet seat, grab rails, and a dressing stick. Adaptations required: Adaptations to the home environment to improve accessibility. Therapy input / interventions: Occupational therapy sessions twice a week for 6 weeks. Education provided: Education on energy conservation techniques and home safety. Referrals made (e.g., physio, social services, falls team): Referral to physiotherapy. --- 10. Summary / Clinical Impression The patient presents with significant functional limitations following a stroke. He requires assistance with most activities of daily living. The patient is motivated to improve his independence. The patient would benefit from OT and PT interventions. --- 11. Action Plan / Follow-Up Next review date: 1 December 2024 Planned sessions: Two OT sessions per week. Discharge / onward referral details: Ongoing OT and PT input. Review in one month.