Initial Occupational Therapy Assessment

Outpatient Occupational Therapy Initial Assessment Reason for Referral: Referral from Dr. Sarah Chen, General Practitioner, due to a recent fall at home resulting in a fractured wrist and subsequent decline in independent living skills. Patient has expressed difficulty with daily self-care tasks and household management. Occupational Profile: Client is a 72-year-old female, Mrs. Eleanor Vance. She lives alone in a formal, two-story house with stairs, and has been a widow for five years. She retired 10 years ago from her career as a primary school teacher. She receives a state pension but no additional grant support. She has two adult children who live out of town and visit monthly. She is highly independent and values maintaining her autonomy within her home and community. Client Goals: Mrs. Vance's primary goals are to regain full independence in her personal care activities, particularly dressing and bathing, and to safely manage meal preparation and light household chores. She also wishes to resume her weekly gardening hobby and social outings with friends, which have been impacted by her reduced mobility and confidence following the fall. Occupational Performance Issues: Significant difficulties are noted in daily living tasks, specifically dressing (fastening buttons, pulling up trousers), bathing (stepping into the shower, reaching for soap), and toileting (maintaining balance). Instrumental tasks are also challenging, including cooking (lifting pots, chopping vegetables) and light housework (dusting, carrying laundry). She reports a reduced ability to participate in community activities due to fear of falling and difficulty navigating public transport with her current physical limitations. Cognitive and Psychosocial Function: No significant cognitive difficulties were observed during the assessment; Mrs. Vance demonstrated good attention, memory, and problem-solving skills. However, she expressed considerable emotional distress and anxiety related to her recent fall, impacting her confidence and willingness to engage in previously enjoyed activities. She reports feelings of frustration and a fear of becoming a burden to her children. Physical Function and Functional Capacity: Mrs. Vance presents with limited range of motion and strength in her right wrist due to the recent fracture. Fine motor coordination is impaired, affecting tasks requiring precision (e.g., buttoning). Gross motor function is generally fair, but she demonstrates reduced balance and endurance, particularly when standing for extended periods or navigating stairs. She requires verbal cues and occasional physical assistance for transfers and ambulation over uneven surfaces. Assessment Tools Administered: Canadian Occupational Performance Measure (COPM) – identified self-care, productivity, and leisure as key areas of concern. Barthel Index – indicated moderate dependency in several ADLs. Observational task performance during simulated dressing and meal preparation tasks. Environmental Context: The client's home has stairs to the bedroom and bathroom, presenting a significant barrier. The bathroom has a high-sided bath/shower combination. No assistive devices are currently in use. Her children provide some support with groceries and transportation, but a formal caregiver is not present. Public transport accessibility is a concern due to physical limitations. Summary of Assessment: Mrs. Vance is a 72-year-old independent woman experiencing significant functional decline following a wrist fracture. Her primary challenges are in self-care and home management due to physical limitations and a notable decline in confidence and increased anxiety. Environmental barriers, particularly stairs and the bathroom setup, exacerbate these difficulties, impacting her overall occupational performance and participation in valued life roles. Initial Plan / Recommendations: Proposed intervention areas include ADL retraining with a focus on compensatory strategies and adaptive equipment for dressing, bathing, and toileting. Caregiver education for her children regarding support techniques. Functional rehabilitation to improve wrist strength, range of motion, balance, and endurance. Prescription of appropriate assistive devices (e.g., shower chair, grab bars, long-handled reacher). Development of a home exercise programme. Referral to a social worker for potential home modification assessment and transport solutions. Liaison with her general practitioner regarding her anxiety. "This set of notes has been produced with the assistance of an AI-scribing service. I confirm that verbal consent has been obtained from the patient. I have reviewed the content of notes and confirm that these are a full and accurate record of my clinical assessment."