Hand Therapy Assessment: Occupational Therapy

Referring Physician: [Physician's Name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Diagnosis: [Primary diagnosis related to injury or condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Chief Complaint: - [Describe the patient's main complaint or reason for referral, such as pain, dysfunction, or specific challenges with hand/wrist/elbow function.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) History of Present Illness: - [Provide a detailed description of how the injury occurred or the condition developed. Include information such as time of onset, mechanism of injury, aggravating or relieving factors, and functional limitations.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Pain Assessment: - [Ask the patient to describe the pain intensity (e.g., mild, moderate, severe), quality (sharp, aching, burning), and duration. Include any aggravating or relieving factors.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Previous Treatments: - [List any treatments the patient has tried, including medications, physical therapy, braces, splints, or other interventions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Observation: - [Include any notable visual observations related to the hand, wrist, or elbow. This may include swelling, redness, bruising, or deformities.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Range of Motion (ROM): - [Assess active and passive range of motion for the affected joints.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) - Wrist Flexion: [Value] - Wrist Extension: [Value] - Wrist Radial Deviation: [Value] - Wrist Ulnar Deviation: [Value] - Elbow Flexion/Extension: [Value] - Other relevant ROM measurements. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Strength Testing: - [Perform and document strength assessments using a grip dynamometer, pinch gauge, or manual muscle testing.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) - Grip strength: [Value] (affected hand), [Value] (unaffected hand) - Pinch strength: [Value] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Sensory Testing: - [Assess for any sensory deficits using light touch, two-point discrimination, or monofilament testing, if appropriate.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Functional Assessment: - [Evaluate the patient's ability to perform functional tasks related to hand, wrist, and elbow use, such as grasping, lifting, typing, or performing daily self-care activities.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Special Tests: - [Include any relevant special tests, such as Phalen’s test for carpal tunnel syndrome or Tinel’s sign for nerve irritation.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Diagnosis: - [Provide a clinical impression based on the subjective and objective findings.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Functional Limitations: - [Describe the patient’s limitations based on the assessment, including impact on daily life, work, and recreational activities.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Prognosis: - [Provide a prognosis based on the patient’s condition and response to initial assessment.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Treatment Goals: - [List short-term and long-term goals for the patient’s therapy.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) 1. **Short-term**: [Short-term goals] 2. **Long-term**: [Long-term goals] Interventions: - [Specify the treatment plan and interventions for the patient.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) 1. [Intervention 1] 2. [Intervention 2] 3. [Intervention 3] 4. [Intervention 4] 5. [Intervention 5] Modalities: - [Include any modalities, such as hot/cold therapy, ultrasound, or TENS, that will be used in treatment.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Education: - [Provide patient education regarding posture, ergonomic recommendations, and activity modification.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Frequency and Duration: - [Specify the frequency and duration of therapy.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) Follow-up: - [Set a follow-up schedule for re-assessment.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) (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.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)