Cardinal Hill Occupational Participation Process Process: Adult INSERT Occupational Profile

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1 appendix BA Cardinal Hill Occupational Participation Process Process: Adult INSERT Occupational Profile Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Perplaski et al. Copyright 2009, by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of American Occupational Therapy Association; to apply, visit 339

3 Appendix B: Adult Occupational Profile Cardinal Hill Occupational Participation Process Adult Occupational Profile Client Name: Client #: DOB: Initial Date: Discharge Date: Diagnosis: Precautions: 1. Client lives with alone in a house trailer apt. with steps to enter R L handrail; stories; steps inside home. 2. Client s discharge environment, resources, and available adaptive equipment: 3. Before this hospitalization, the client was I req d assistance in BADLs and I req d assistance in IADLs. Client needed assistance with 4. A typical day consists of: wake-up time a.m. p.m.; volunteer work; bedtime a.m. p.m. 5. What activities do you participate in for fun, and how often? 6. How do you learn best? (In rehab you will be learning new things. Do you learn best by reading, watching a video?) 7. How familiar are you with technology? 8. What motivates you to improve? 9. How are you coping with your current status? Initial Identify 5 occupations that are meaningful to you and that you want to resume/learn. (Ask clients to rate their satisfaction with their current ability to perform role [1 10].) Discharge Client s satisfaction with resuming roles (1 10). Therapist s Signature date Therapist s Signature date Note. R/L = right/left; I = independent; BADLs = basic activities of daily living; IADLs = instrumental activities of daily living. Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 341

5 appendix C Cardinal Hill Occupational Participation Process Adult Occupational Analysis Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Perplaski et al. Copyright 2009, by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of American Occupational Therapy Association; to apply, visit 343

7 Appendix C: Adult Occupational Analysis Cardinal Hill Occupational Participation Process Adult Occupational Analysis Client Name: Client #: DOB: Initial Date: Discharge Date: Diagnosis: Precautions: Initial Discharge 1. Basic ADLs Eating Grooming Bathing e/w/s Dressing UB E/W/S e/w/s Dressing LB E/W/S Toilet Tx Tub/Shower Tx problem Solving Memory Comments Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 345

8 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge 2. Instrumental ADLs Community Mobility Health Management/Prevention Home Management Financial Management Leisure Safety Comments 3. Motor and Praxis Skills Sitting Static/Dynamic Standing Static/Dynamic Joint Stability and Skeletal Mobility 346

9 Appendix C: Adult Occupational Analysis Client Name: Client #: Initial Discharge Place Can on Shelf Retrieve Item From Floor Screw Lid on Jar Comb Back of Head Write Name Lift Grocery Bag Comments 347

10 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge Energy for Task Coordination L R Grip Strength/Lateral Pinch lbs/3 Jaw Chuck L R Knowledge/Organization of Task Adaptation/Praxis Comments 4. Communication and Social Skills 5. Cognitive and Emotional Regulation Skills Level of Arousal/Attention Orientation Energy and Drive 348

11 Appendix C: Adult Occupational Analysis Client Name: Client #: Initial Discharge 6. Higher Level Cognition 7. Sensory Perceptual Skills Sensory Visual Self-Perception pain Skin Integrity Comments on on Sensory Perceptual Skills Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post HR O2 RPD HR O2 RPD HR O 2 RPD HR O 2 RPD General Comments 349

12 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge How do the risks interfere with participation in occupation? How has occupational therapy facilitated participation in occupation in client s environment? equipment: Equipment provided: Goals met: Goals not met: ELOS: Number of visits: Reason for discharge: D/C recommendations/referrals: Therapist s Signature date Therapist s Signature date Note. ADLs = activities of daily living; E/W/S = edge of bed/wheelchair/supine; UB = upper body; LB = lower body; Tx = transfer; HR = heart rate; O2 = oxygen; RPD = rate of perceived dyspnea; ELOS = estimated length of stay; D/C = discharge. 350

13 appendix D Cardinal Hill Occupational Participation Process Inpatient Intervention Plan Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009, by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of American Occupational Therapy Association; to apply, visit 351

15 Appendix D: Inpatient Intervention Plan Cardinal Hill Occupational Participation Process Inpatient Intervention Plan Client: Client #: DOB: Admit Date: Decreased satisfaction/ability to participate in the following occupations: Eating Tub/Shower Transfer Social Participation Grooming Community Mobility Shopping Bathing Safety/Emergency Response Education UB Dressing Financial Management Work LB Dressing Health Management/Prevention Leisure/Play Toilet Transfer Home Management Functional Mobility Rest and Sleep Performance risks that interfere with participation in occupations: Problem Solving Neuromuscular/Movement Skin Integrity Memory Oral Motor/Dysphagia Pain Cognition Mobility Organization/Adaptability Posture Coordination Sensory Functions Energy/Endurance Strength/Effort Vision Functions Perception Strengths (contextual influences): Short-term goals: Discharge Goals/Rehab Potential: Client will demonstrate: 1. Eating with using 2. Grooming with using w/c level walker level standing 3. Bathing with using sponge bath tub bath 4. Upper body dressing with using EOB w/c level supine 5. Lower body dressing with using EOB w/c level supine 6. Toilet transfer with using w/c level walker level 7. Tub/shower transfer with using w/c level walker level 8. Problem solving with 9. Memory with 10. Light homemaking activities with using w/c level walker level Client/Family will: 11. Demonstrate knowledge to assist client with ADLs as needed 12. Perform home program with assistance 13. Participate in community outing with assistance w/c level walker level 14. Demonstrate use of equipment with assistance 15. Engage in leisure exploration and/or participation with Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 353

16 Applying the Occupational Therapy Practice Framework Plan of Treatment/Education in: ADLs Work/Productive Activities Psychosocial Positioning Neuromuscular Movement Cognitive Activities Sensory Activities Aquatics Skin/Edema Splinting/Casting Perceptual Tasks Leisure Modalities Oral Motor/Swallowing Reevaluation Co-Treat Adaptive Equipment D/C Planning Home Visit Health Management/ Home Program Client/Caregiver Education Home Safety/Equipment Prevention Other Frequency: Duration: Medical Diagnosis: OT Diagnosis: Contraindications/Precautions: I certify that occupational therapy services are necessary under a plan to be periodically reviewed by me and while the patient is under my care. Date Therapist s Signature accepted Date physician s Signature Note. w/c = wheelchair; EOB = edge of bed; ADLs = activities of daily living; D/C = discharge; OT = occupational therapist. 354

17 appendix E Cardinal Hill Occupational Participation Process Home Care Evaluation Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009, by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of American Occupational Therapy Association; to apply, visit 355

19 Appendix E: Home Care Evaluation Cardinal Hill Occupational Participation Process Home Care Evaluation Client Name: Client #: DOB: Initial Date: Discharge Date: Diagnosis: Precautions: Initial Discharge 1. Basic ADLs Eating Grooming Bathing E/W/S Dressing UB E/W/S E/W/S Dressing LB E/W/S Toilet Tx Tub/Shower Tx Problem Solving Memory Comments Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 357

20 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge 2. Instrumental ADLs Community Mobility Health Management/Prevention Home Management Financial Management Leisure Safety Comments 3. Motor and Praxis Skills Sitting Static/Dynamic Standing Static/Dynamic Joint Stability and Skeletal Mobility 358

21 Appendix E: Home Care Evaluation Client Name: Client #: Initial Discharge Place Can on Shelf Retrieve Item From Floor Screw Lid on Jar Comb Back of Head Write Name Lift Grocery Bag Comments 359

22 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge Energy for Task Coordination L R Grip Strength/Lateral Pinch lbs/3 Jaw Chuck L R Knowledge/Organization of Task Praxis Comments 4. Communication and Social Skills 5. Cognitive and Emotional Regulation Skills Level of Arousal/Attention Orientation Energy and Drive 360

23 Appendix E: Home Care Evaluation Client Name: Client #: Initial Discharge 6. Higher Level Cognition 7. Sensory Perceptual Skills Sensory Visual Self-Perception Pain Skin Integrity Comments on Sensory Perception Skills Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post HR O 2 RPD HR O 2 RPD General Comments 361

24 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge How do the risks interfere with participation in occupation? How has occupational therapy facilitated participation in occupation in client s environment? Equipment: Equipment provided: Goals met: Goals not met: ELOS: Number of visits: Reason for discharge: D/C recommendations/referrals: Therapist s Signature date Date Therapist s Signature date Date Note. ADLs = activities of daily living; E/W/S = edge of bed/wheelchair/supine; UB = upper body; LB = lower body; Tx = transfer; HR = heart rate; O2 = oxygen; RPD = rate of perceived dyspnea; ELOS = estimated length of stay; D/C = discharge. 362

25 appendix F Cardinal Hill Occupational Participation Process Home Care Intervention Plan Checklist 363

27 Appendix F: Home Care Intervention Plan Checklist Cardinal Hill Occupational Participation Process Home Care Intervention Plan Checklist Client: Client #: DOB: Admit Date: Decreased satisfaction/ability to participate in the following occupations: Eating Tub/Shower Transfer Social Participation Grooming Community Mobility Shopping Bathing Safety/Emergency Response Education UB Dressing Financial Management Work LB Dressing Health Management/Prevention Leisure/Play Toilet Transfer Home Management Functional Mobility Rest and Sleep Performance risks that interfere with participation in occupations: Problem Solving Neuromuscular/Movement Skin Integrity Memory Oral Motor/Dysphagia Pain Cognition Mobility Organization/Adaptability Posture Coordination Sensory Functions Energy/Endurance Strength/Effort Vision Functions Perception Strengths (contextual influences): Short-term goals: Assessment to functional deficits to be completed with client participation in goal making Educational/assistive equipment needs to be addressed with client / family verbalized understanding Home safety to be addressed, recommendations written with client / family verbalized understanding Home activity program to be initiated to increase or ease in occupational participation Energy conservation principles / pursed lip breathing / posture to be reviewed with client demonstrated understanding % of the time Discharge goals/rehab potential: Client will demonstrate Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 365

28 Applying the Occupational Therapy Practice Framework Plan of Treatment/Education in: ADLs Work/Productive Activities Psychosocial Skills Positioning Neuromuscular/movement Cognitive Activities Sensory Activities Aquatics Skin/Edema Splinting/Casting Perceptual Tasks Leisure Modalities Oral Motor/Swallowing Reevaluation Co-Treat Adaptive Equipment D/C Planning Home Visit Health Management/ Home Program Client/Caregiver Education Home Safety/Equipment Prevention Other Frequency: Duration: Medical Diagnosis: OT Diagnosis: Contraindications/Precautions: Plan of Treatment: Discharge Plan: Good Fair Poor Home Independently Home with Caregiver Assisted Living I certify that occupational therapy services are necessary under a plan to be periodically reviewed by me and while the patient is under my care. Date Occupational Therapist s Signature Accepted Date Reviewing Physician s Signature Reviewing Physician s Name Reviewing Physician s Signature Referring Physician s Name Note. ADLs = activities of daily living; D/C = discharge; OT = occupational therapist. 366

29 appendix G Cardinal Hill Occupational Participation Process Pediatric Evaluation 367

31 Appendix G: Pediatric Evaluation Cardinal Cardinal Hill Occupational Hill Healthcare Participation System Process Occupational Pediatric Analysis Evaluation (Pediatric) Client Name: Client #: DOB: Initial Date: Discharge Date: Diagnosis: Precautions: Age: Grade in School: Physician: Initial Discharge Basic ADLs Eating/Oral Motor Grooming Bathing/Transfer Dressing Upper Body Dressing Lower Body Toilet Training/Transfer Problem Solving/Memory Comments Age Equivalent Percentile Standard Score Standardized ADL Test Age Equivalent Percentile Standard Score Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 369

32 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge Instrumental ADLs Community Mobility Home Management Play Exploration Play Participation Safety Comments Motor and Praxis Skills Supine Flexion Posture Prone Extension Posture Sitting Posture/Balance Developmental Positions Muscle Functions 370

33 Appendix G: Pediatric Evaluation Client Name: Client #: Initial Discharge Movement Function Reflexes Comments Energy for Task Coordination Manipulation Visual/Motor Adaptation/Praxis Comments Age Equivalent Percentile Standard Score Standardized Motor Test Age Equivalent Percentile Standard Score Age Equivalent Percentile Standard Score Standardized Motor Test Age Equivalent Percentile Standard Score 371

34 Applying the Occupational Therapy Practice Framework Client Name: Client #: Initial Discharge Communication and Social Skills Cognitive and Emotional Regulation Skills Level of Arousal/Attention Energy and Drive Comments Sensory Perceptual Skills Typical Atypical Standardized Sensory Test Typical Atypical Vision/Hearing Age Equivalent Percentile Standard Score Standardized Visual Perception Test Age Equivalent Percentile Standard Score Visual Perception Comments 372

35 Appendix G: Pediatric Evaluation Client Name: Client #: Initial How do the risks interfere with participation in occupation? Discharge How has occupational therapy facilitated participation in occupation in client s environment? Identify 5 occupations that are meaningful to you and that you want to resume/learn. (Ask clients to rate their satisfaction with their current ability to perform role [1 10]). Client s satisfaction with resuming roles (1 10). Equipment: Equipment provided: Duration: Number of visits: Reason for discharge: Discharge goals met: Discharge goals not met: Patient/family education: Discharge recommendations/referrals: Therapist s Signature Date Therapist s Signature Date 373

37 appendix H Cardinal Hill Occupational Participation Process Outpatient Intervention Plan 375

39 Cardinal Cardinal Hill Occupational Hill Healthcare Participation System Process Outpatient Intervention Form Plan Appendix H: Outpatient Intervention Plan Client: Client #: DOB: Decreased satisfaction/ability to participate in the following occupations: Eating Tub/Shower Transfer Social Participation Grooming Community Mobility Shopping Bathing Safety/Emergency Response Education UB Dressing Financial Management Work LB Dressing Health Management/Prevention Leisure/Play Toilet Transfer Home Management Functional Mobility Rest and Sleep Performance risks that interfere with participation in occupations: Problem Solving Neuromuscular/Movement Skin Integrity Memory Oral Motor/Dysphagia Pain Cognition Mobility Organization/Adaptability Posture Coordination Sensory Functions Energy/Endurance Strength/Effort Vision Functions Perception Strengths (contextual influences): Short-term goals: Discharge goals/rehab potential: Plan of Treatment/Education in: ADLs Work/Productive Activities Psychosocial Skills Positioning Neuromuscular Cognitive Activities Sensory Activities Aquatics Skin/Edema Splinting/Casting Perceptual Tasks Leisure Modalities Oral Motor/Swallowing Reevaluation Co-Treat Adaptive Equipment D/C Planning Home Visit Health Management/ Home Program Client/Caregiver Education Home Safety/Equipment Prevention Other Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 377

40 Applying the Occupational Therapy Practice Framework Frequency: duration: Medical diagnosis: OT diagnosis: Contraindications/precautions: I certify that occupational therapy services are necessary under a plan to be periodically reviewed by me and while the patient is under my care. date Occupational Therapist s Signature accepted date Reviewing physician s Signature Reviewing physician s name Reviewing physician s Signature Referring physician s name Note. Note: adls ADLs = activities of daily living; d/c D/C = discharge; HpOT = occupational = hippotherapy; therapist. OT = occupational therapist. 378

41 appendix I Cardinal Hill Occupational Participation Process Sensation Addendum 379

43 Appendix I: Sensation Addendum Cardinal Hill Occupational Participation Process Sensation Addendum Client Name: Client #: Occipital protrub. C2 C3 I II III }Divisions of trigeminal n. 3T 6T 1L C4 7C T4 L2 T L1 T Sharp/Dull Right Left Int Imp Abs Int Imp Abs C3 C4 C5 C6 C7 C8 T1 T2 Temperature Right Left Int Imp Abs Int Imp Abs C3 C4 C5 C6 C7 C8 T1 T2 Light Touch Right Left Int Imp Abs Int Imp Abs C3 C4 C5 C6 C7 C8 T1 T2 C5 T1 C5 T1 Position Sense Radial fingers Ulnar fingers Thumb Wrist Forearm rot. Elbow Shoulder T1 C C2 C4 T Right Left Int Imp Abs Int Imp Abs Object Identification Right Left Int Imp Abs Int Imp Abs Comments: Note. protrub. = protuberance; n. = nerve; rot. = rotation; Int = internal rotation; Imp = impaired; Abs = absent. Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 381

45 appendix J Cardinal Hill Occupational Participation Process: Range-of-Motion Addendum 383

47 Appendix J: Range-of-Motion Addendum Cardinal Hill Occupational Participation Process Range of Motion Addendum Client Name: Client #: Initial Range of Motion Discharge AROM PROM AROM PROM L R L R Joint Motion ROM L R L R Shoulder Flexion 180 Shoulder Abduction 180 Shoulder Int. Rotation 70 Shoulder Ext. Rotation 90 Shoulder Horiz. Abduction 90 Shoulder Horiz. Adduction 45 Elbow Flexion 135 Elbow Extension 0 Forearm Pronation 70 Forearm Supination 80 Wrist Flexion 75 Wrist Extension 70 Wrist Ulnar Deviation 30 Wrist Radial Deviation 15 MCP 1 Flexion 90 MCP 2 Flexion 90 MCP 3 Flexion 90 MCP 4 Flexion 90 MCP 1 Extension 0 MCP 2 Extension 0 MCP 3 Extension 0 MCP 4 Extension 0 PIP 1 Flexion 100 PIP 2 Flexion 100 PIP 3 Flexion 100 PIP 4 Flexion 100 PIP 1 Extension 0 PIP 2 Extension 0 PIP 3 Extension 0 PIP 4 Extension 0 DIP1 Flexion 90 DIP2 Flexion 90 DIP3 Flexion 90 DIP4 Flexion 90 DIP1 Extension 0 DIP2 Extension 0 DIP3 Extension 0 DIP4 Extension 0 Thumb MP Flexion 50 Thumb MP Extension 0 Thumb IP Flexion 80 Thumb IP Extension 0 Scapula: Pain: Edema: Contracture: Spasticity: Splints Indicated: Note. AROM = active range of motion; PROM = passive range of motion; Int = internal rotation; Ext = external rotation; Horiz = horizontal; IP = interphalangeal; MCP = metacarpal phalangeal joints; PIP = proximal interphalangeal joints; DIP = distal interphalangeal joints; MP = motor planning. Note: This form is provided for use with Applying the Occupational Therapy Practice Framework: The Cardinal Hill Occupational Participation Process, 2nd Edition, by C. Skubik-Peplaski et al. Copyright 2009 by the American Occupational Therapy Association. This form may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission of the American Occupational Therapy Association; to apply, visit 385

Table of Contents Treatment Guides Basic Activities of Daily Living Basic and Instrumental Activities of Daily Living 11 Bathing and Showering 13 Dres

Table of Contents Treatment Guides Basic Activities of Daily Living Basic and Instrumental Activities of Daily Living 11 Bathing and Showering 13 Dres Treatment Guides Basic Activities of Daily Living Basic and Instrumental Activities of Daily Living 11 Bathing and Showering 13 Dressing 15 Feeding 18 Functional Communication 20 Functional Mobility 22