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APPENDIX 3.A. OCCUPATIONAL THERAPY EVALUATION FORM Time in/out: | Patient name: Age: Medical record bical Te els Fee, at Diagnosis: Precautions: Preadmission status: Living arrangement: Alone with family Other: oLevel home Anticipated living arrangement at discharge: Roles: oWorker Driving: oyYes DStep entry (ramp) oStuder No nt Prior Level of Function (circle all that apply) Overall ADLs D Overall Mobility OD Mod Mod oOthe: other: coCaregiver/parent oHomemaker/maintainer Leisure participant Min CGA Sup \ Min CGA Sup I Note. ADLs = activities of daily living; CGA = contact guard assist; D = dependent; | = independent, Max = maximum assist; Min = minimal assist; Mod = moderate assist; Mod | = modified independent; ‘Sup = supervision. Durable medical equipment (DME) prior to admission: Patient perception of occupational needs and goals: Current Level of Performance (circle all that apply) {AREAS OF OCCUPATION ADLs Feeding Grooming Dressing UB Dressing LB Toileting IADLs Work or schoo! Leisure and social participation Note, ADLs = activities of dally living; CGA = contact guard assist; D = dependent; | = independent; IADLs = minimal assist; Mod = moderate assist; Mod | = modified independent; Sup = supervision; UB Min = LEVEL OF PERFORMANCE OR ASSISTANCE i D Max Max Max Max Max Max Max Max Mod Mod Mod Mod Mod Mod Mod Mod Min Min Min Min Min Min Min Min CGA CGA CGA CGA CGA CGA CGA CGA Sup Sup Sup Sup Sup Sup Sup Sup Mod | Mod | Mod { Mod | Mod! Mod | Mod | Mod | Mobility Sensory—Motor Cognitive-Perceptual Communication Psychosocial Environment/Context FACTORS AFFECTING OCCUPATIONAL PERFORMANCE Other ! instrumental activities of dai xi laily living; LB = body; Max = m: = upper body, 'y living; lower ‘other Neuromusculoskeletal Performance (enter measurement results) ‘LUE ULE Note, LLE = lef lower extremity; LUE = left upper extremity; MMT = manual muscle testing; RLE = right lower extremity; ROM = range of motion; RUE = right upper extremity. Comments: rote a Shoulder ; Elbow Wrist Digits Coordination Gross control—finger to nose Fine control Sensation Light touch, pain Proprioception Stereognosis Strength Gross grasp MMT—shoulder MMT—elbow, forearm, wrist MMT—grip, opposition, lateral pinch, and tip-tip Tone, clonus Edema ROM Hip Knee Ankle Coordination Heel slide Sensation Light touch Propriaception Strength MMT—hip MMT—knee MMT—ankle Tone, clonus Edema CHAPTER 3 Evaluation of Acute Care Patients RLE COMMENTS £3] COMMENTS (Continued) Streng! ths and Factors Impeding Performance (circle all that apply) STRENGTHS scenes @ Pnor level of function @ Cognition and percepbon @ Social support Note. ADL = activity of daily living; ROM = range of motion. Rehabilitation Potential _ GOAL ‘Short-term goals (to be accomplished in visits): FACTORS POTENTIALLY IMPEDING PERFORMANCE 4 Prior level of function {Psychological state | Cognition and insight 4 Visual skills | Perceptual skills 1 Physiological function | Physical (strength, ROM, motor control) 4 Social support {ADL function Safety {Communication | Functional mobility MEASURE OF ATTAINMENT 1 2. 3. Long-term goals (to be accomplished in visits): 1 2 3. Intervention Plan Patient to be seen for skilled occupational therapy services __ x week for__ OActivities of daily living retraining ‘Functional mobility and transfer training Strengthening, endurance, range of motion Cognitive-perceptual remediation ‘Functional balance training ‘OSplinting/orthotics Adaptive equipment Patient and caregiver education for sate discharge OOther: weeks for the following interventions (check all that apply): Patient and/or caregiver were informed of the treatment plan and are in agreement with above-stated goals. Therapist signature: Date: 
