Occupational Therapy Consult Note

Skabelonstruktur

Dette er den struktur, som Notat følger, når den skriver notatet fra konsultationen — du udfylder den aldrig i hånden.

Occupational Therapy Note

Patient Identification: [Patient name, age, gender, relevant medical history, reason for referral]

Past Medical History:
(hyphenated list)
- [Relevant medical diagnoses]
- [Surgical history]
- [Psychiatric history if applicable]

Functional Status:
(hyphenated list)
- [ADLs: bathing, dressing, grooming, toileting, feeding]
- [IADLs: cooking, cleaning, shopping, managing finances]
- [Mobility: transfers, ambulation, use of mobility aids]
- [Cognitive function: memory, attention, executive function]
- [Communication abilities]
- [Leisure activities and interests]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Musculoskeletal: range of motion, strength, tone, coordination]
- [Neurological: sensation, balance, proprioception]
- [Observation of functional tasks]

Assessment:
(hyphenated list)
- [Summary of functional deficits and strengths]
- [Barriers to independence]
- [Rehabilitation potential]
- [Relevant diagnoses]

Plan:
(hyphenated list)
- [Interventions planned: therapeutic activities, adaptive equipment, environmental modifications]
- [Education provided to patient/caregivers]
- [Goals: short-term and long-term]
- [Referrals to other services]
- [Frequency and duration of therapy]
- [Follow up plan]
- [Return precautions or instructions]