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Get the free OT / PT Case History Form PATIENT INFORMATION

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OT / PT Case History Form Person completing this form: Date: Relationship to child: PATIENT INFORMATION Child's name: Date of Birth: Grade: School: Any other services they are receiving: PT OT CDS
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How to fill out ot pt case history

01
First, gather all necessary information about the patient, including their personal details, medical history, and current condition.
02
Next, start by documenting the patient's demographics, such as their age, gender, and contact information.
03
Then, proceed to record the patient's medical history, including any previous diagnoses, surgeries, or treatments they have undergone.
04
In the case history, make sure to also include information about the patient's current condition or chief complaint that brought them to seek occupational or physical therapy.
05
Next, document any medications the patient is currently taking, as well as any known allergies they may have.
06
Perform a thorough assessment of the patient's physical abilities, including range of motion, strength, coordination, and balance.
07
Based on the assessment, develop treatment goals and outline a plan of care for the patient.
08
Include details about the treatment interventions, exercises, or modalities that will be used to address the patient's specific needs.
09
Continuously evaluate the patient's progress and make necessary adjustments to the treatment plan as needed.
10
Finally, ensure that all documentation is completed accurately, including signatures and dates, and securely store the case history for future reference and legal purposes.

Who needs ot pt case history?

01
Occupational therapists (OT) and physical therapists (PT) need the case history to provide optimal care and treatment to their patients.
02
Patients who seek occupational or physical therapy services also need their case history to ensure that the therapist understands their unique needs and can develop a personalized treatment plan.
03
Other healthcare professionals or medical specialists may also require access to the case history to provide collaborative care and make informed decisions about the patient's treatment.
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OT PT case history is a detailed record of a patient's medical history, including information about their current condition, past treatments, and any relevant test results.
Physical therapists and occupational therapists are required to file OT PT case histories for their patients.
OT PT case histories should be filled out with accurate and detailed information about the patient's medical history, current condition, and treatment plan.
The purpose of OT PT case history is to provide a comprehensive overview of the patient's medical background and help therapists develop an effective treatment plan.
Information such as the patient's medical history, current condition, treatment plan, and any relevant test results must be reported on an OT PT case history.
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