Initial Assessment OT
Date of Ax: [date] Persons present: [text] Settting : [checkbox name="Social" value="Residential aged care facility. |Private residence."] Client name: [textarea name="Client Name"] [checkbox name="Sex " value="Male|Female"] DOB: [date] Diagnosis: [checklist name="Diagnosis" value="Cerebral vascular disease |Congestive heart failure |COPD |Dementia|Degenerative disc disease|Falls |Diabetic neuropathy|Dialysis |Dizziness|Fixed hip angle |Hemiplegia|Muscle weakness |Obesity|Pressure ulcer|SCI|Osteoarthritis|Parkinson’s disease|Rheumatoid arthritis |Traumatic brain injury |Upper body instability |Wheelchair user |Age-related Decline"] Social history: [checkbox name="Social" value="Living at home alone. |Living at home with support. |Living with family/husband/partner|"] Supports/services: [checklist name="services " value="Domestic cleaning|Gardening|Personal carers|Shopping|Community Access|Meal preparation"] Falls History: [checkbox value="None|Occasional|Frequent|Risk of falls"] Skin Breakdown: [checkbox value="Present|None currently|History of"] Ambulation: Maximum distance ambulated independently: [checkbox value="<10m|>10m|>20m|>50m|>100m"] Cane/SPS:[checkbox value="not using|unable to use d/t upper extremity weakness|unable to use d/t upper extremity pain|unable to use d/t lower extremity weakness|unable to use d/t dizziness"] 4WF/Walker:[checkbox value="not using|limited use d/t fatigue|limited use d/t dizziness|uses with assistance|unable to use independently d/t upper extremity weakness|unable to use independently d/t upper extremity limited range of motion|unable to use independently d/t upper extremity pain with motion|unable to use independently d/t lower extremity weakness"] Manual Wheelchair: [checkbox value="wheeled by staff|unable to use independently d/t upper extremity weakness|unable to use independently d/t dementia"] Powered Wheelchair: [checkbox value="Pending Cognitive Ax. |unable to use independently d/t dementia"] Progression of ambulation difficulty over time: [checkbox value="improving|deteriorating|unchanged"] ACTIVITIES OF DAILY LIVING Reports limited activities of daily living d/t: [checklist name="services " value="upper extremity weakness|upper extremity spasticity|lower extremity weakness|lower extremity spasticity|poor standing balance|poor sitting balance|poor coordination|poor endurance evidenced by shortness of breath with exertion|oxygen use|frequent falls|dizziness|Fatigue"] ADLs requiring the assistance: [checklist name="services " value="Getting in/out of bed|Dressing/undressing|Showering (washing) |Showering (Drying)|Grooming|Transfer between bed, chair, & mobility device|Toileting|Ambulating around the home.|Feeding|Light meal preparation|Complex meal preparation|Light cleaning |Heavy cleaning|Accessing the Community"] PHYSICAL EXAM Weight: [text name="Weight"] Height:[text name="Weight"] Hip Width: [text name="Weight"] Shoulder Width: [text name="Weight"] Shoulder Height: [text name="Weight"] Lower leg length: [text name="Weight"] Thigh/buttocks length:[text name="Weight"] Posture: [checkbox value="Healthy Posture.|Kyphosis Posture.|Flat Back Posture.|Swayback Posture.|Forward Head Posture"] Tremor: [checkbox value="Yes |No "] Vision: [checkbox value="grossly intact|wearing glasses"] Hearing: [checkbox value="grossly intact to conversation|hard of hearing|very HOH|wearing hearing aid"] Cognition: [checkbox value="A/O x3|able to answer questions without difficulty|unable to answer questions|STML. "] Neck: [checkbox value="normal exam|decreased ROM|pain with motion"] Upper Extremity: [checkbox value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"] Lower Extremity: [checkbox value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"] Sit to stand transfers:[checkbox value="without difficulty|with significant difficulty|unable to perform independently"] Gait: [checkbox value="without difficulty|non-ambulatory|shuffling|ataxic|wide|max assist|mod assist|stops every few steps to rest|diaphoresis|tachycardia|tachypnea"] Skin: [checkbox value="grossly intact|wounds|Dry/flaky skin"] NARRATIVE: This is a [textarea name="variable_1" default="sample text"] y/o patient with several health problems worsening gradually over the past year. The client is experiencing difficulty engaging in their ADL'S safely and independently whilst living at home d/t:[textarea name="variable_1" default="sample text"]. To work towards the client's goals and improve his/her safety and independence OT is recommending:
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.72, 39 form elements, 136 boilerplate words, 8 text boxes, 3 text areas, 2 dates, 22 checkboxes, 4 check lists, 165 total clicks
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