NDIS Follow up.

Section: Patient Information * Name: John Smith * Date of Birth: 12/03/1960 * Address: 12 Acacia Avenue, Anytown * Contact Information: 07777 123456 Section: Disability Profile * Primary disability or diagnosis under NDIS: Cerebral Palsy * Secondary conditions: Mild scoliosis * Level of functional impact or support needs: High, requiring assistance with most activities of daily living. Section: Subjective Update * Patient’s or carer’s report of current physical function, comfort, confidence, and mobility: John reports increased pain in his left hip, making transfers more difficult. He feels less confident with walking. * Changes in symptoms including spasticity, fatigue, pain, balance, strength, coordination, endurance: Increased pain in left hip, increased fatigue in the afternoons. * Feedback from support workers, family, or educators: Carer reports increased difficulty with transfers and reduced walking distance. * Engagement with home program or therapy tasks since last session: John has been completing his home exercises 3 times per week. * Barriers to participation or adherence: Pain in left hip is a barrier to completing exercises. Section: Goals * Progress toward short-term goals: * Increase walking distance by 10 meters. * Reduce pain levels from 6/10 to 4/10. * Progress toward long-term goals: * Maintain independence with transfers. * Improve overall mobility and participation in community activities. * New or adjusted goals raised during the session: * Explore strategies to manage hip pain. Section: Objective * Functional observations including transfers, bed mobility, walking, stairs, balance, wheelchair use: * Transfers: Assisted with stand pivot transfer. * Walking: Able to walk 10 meters with a walking frame. * Balance: Moderate balance impairment. * Motor assessment including strength, tone, joint range, coordination, endurance: * Strength: Reduced strength in lower limbs. * Tone: Mild spasticity in left leg. * Joint range: Reduced hip flexion on the left. * Neurological observations such as reflexes, spasticity, proprioception, gait pattern: * Gait pattern: Antalgic gait due to hip pain. * Use of assistive devices such as walker, wheelchair, splints, orthotics: * Uses a walking frame for mobility. * Outcome measures used, e.g., 10m Walk Test, TUG, 5xSTS, Berg, GMFM: * 10m Walk Test: 15 seconds. * Berg Balance Scale: 35/56. Section: Treatment Provided Subsection: Education * Patient and/or carer education on disability management, positioning, stretching, pacing, etc.: Educated John and his carer on pain management strategies, including pacing and activity modification. Subsection: Hands-on therapy (if applicable) * Manual therapy to left hip to reduce pain and improve range of motion. Subsection: Active therapy / exercises * Sit-to-stand training, 3 sets of 5 repetitions. * Balance retraining exercises using a wobble board. * Gait training with walking frame. Section: Assessment * Summary of clinical reasoning and presentation: John presents with increased hip pain and reduced mobility, impacting his functional independence. The pain is likely contributing to reduced participation in his home exercise program. * Barriers or enablers to progress: Pain is a significant barrier. Motivation and carer support are enablers. * Therapist opinion on alignment with NDIS goals: The interventions provided are aligned with John's NDIS goals of improving mobility and independence. Section: Plan * Plan for next sessions including frequency, focus areas: Continue with 2 sessions per week, focusing on pain management, strengthening, and gait training. * Updates to home exercise program: * Increase frequency of hip stretches. * Incorporate gentle strengthening exercises for hip muscles. * Monitoring and adjustment of response to therapy: Monitor pain levels and adjust exercises as needed. * Referral or liaison with other providers: Discuss referral to a pain specialist. * Documentation required for plan reassessment, assistive tech applications, or housing support requests: No further documentation required at this time.