Occupational Therapist Summary/Recommendations

Mr. John Doe is a 78-year-old male with a history of Parkinson's disease and arthritis. He lives alone and has limited family support. SOCIAL: - Lives alone in a single-story home - Limited family support, occasional visits from a neighbor - No active community involvement MEDICAL: - Parkinson's disease - Arthritis AMBULATION: - Uses a walker for mobility - Gait is unsteady with noticeable shuffling - History of two falls in the past six months - Safety measures include grab bars in the bathroom and non-slip mats PERSONAL CARE ADL: - Requires assistance with showering and dressing - Independent with toileting but needs supervision for safety DOMESTIC ADL: - Struggles with meal preparation and housework - Can manage light tasks but needs help with heavier chores COMMUNITY ADL: - No longer drives - Relies on a neighbor for transportation to appointments COGNITION: - Mild cognitive impairment, forgets recent events - Cannot be left alone for extended periods - Requires assistance with medication management and scheduling MAIN CONCERNS: 1. Risk of falls 2. Difficulty with personal care 3. Limited family support 4. Cognitive decline OT RECOMMENDATIONS: 1. Equipment: - Shower chair - Raised toilet seat - Medication organizer 2. Home modifications: - Install additional grab bars in the bathroom - Improve lighting in hallways - Remove tripping hazards like loose rugs Additional observations about the home environment and existing equipment/modifications: The home is generally safe but could benefit from additional lighting and removal of tripping hazards. Client's consent to referrals: Client consents to referrals for home health aide and physical therapy. PLAN: 1. Arrange for a home health aide to assist with personal care 2. Schedule a follow-up visit in one month 3. Coordinate with physical therapy for gait training and balance exercises Jane Smith Occupational Therapist