Occupational Therapist
Date of Session:
1 November 2024
Session Objectives:
Addressed fine motor control for dressing tasks and improved bilateral coordination for meal preparation. Focused on increasing independence in activities of daily living (ADLs) through adaptive strategies.
Intervention Techniques:
Utilised task modification for buttoning (larger buttons, front-fastening garments), sensory integration techniques (tactile input with various textures during dressing practice), and upper limb rehabilitation exercises (stacking cones, transferring objects) to improve dexterity and range of motion. Introduced adaptive cutting board with spikes for vegetable preparation.
Client Participation:
Client, Mrs. Eleanor Vance, aged 72, demonstrated good engagement throughout the session, maintaining focus for 45 minutes. Showed increased motivation when using adaptive equipment, specifically the cutting board. Exhibited mild frustration during buttoning tasks but responded well to verbal encouragement and demonstration. Cooperation was consistently good.
Progress Observed:
Noticed a significant improvement in the efficiency of buttoning, reducing the time taken by approximately 30% compared to the previous session. Bilateral coordination during stirring and chopping tasks for meal preparation showed enhanced fluidity and control. Mrs. Vance independently used the adaptive cutting board with minimal verbal cues.
Adaptations or Supports Used:
A reacher was trialled for retrieving items from higher shelves, which Mrs. Vance found helpful. A non-slip mat was introduced for plate stability during meal preparation. Environmental modifications included adjusting chair height for optimal posture during tasks.
Plan for Next Session:
Focus will be on developing strategies for safe transfers in and out of the bath/shower. Homework assigned: practice using the reacher daily for 5-10 minutes and continue with fine motor exercises. Consider introducing a dressing stick if buttoning progress plateaus.
Date of Session:
[record date] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Session Objectives:
[describe specific functional goals or activities addressed] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Intervention Techniques:
[document methods used (e.g., task modification, sensory integration, upper limb rehab, adaptive equipment)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Client Participation:
[note engagement level, cooperation, motivation, and any behavioural observations] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Progress Observed:
[record any changes in performance, participation, or independence] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Adaptations or Supports Used:
[list any new tools, environmental strategies, or scaffolding techniques trialled] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
Plan for Next Session:
[log therapy focus, homework, or modifications to treatment approach] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)