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This document outlines the initial evaluation of an 83-year-old male patient who underwent C3-C7 laminectomy and fusion surgery and is currently experiencing incomplete quadriplegia. It details his medical history, current symptoms, cognitive and physical assessments, and outlines both short-term and long-term rehabilitation goals to improve his functional mobility and activities of daily living.
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Start by gathering necessary personal information, including the client's name, date of birth, and contact details.
02
Fill out the referral source details to indicate who requested the evaluation.
03
Provide a detailed medical history, including diagnoses, past treatments, and any relevant medical conditions.
04
Assess the client's previous and current level of functioning in daily activities.
05
Document specific goals or concerns that the client may have regarding their therapy.
06
Include any relevant social and environmental factors that may impact the client's therapy.
07
Sign and date the form to verify that the information is complete and accurate.

Who needs occupational formrapy initial evaluation?

01
Individuals who have been diagnosed with a condition affecting their ability to perform daily activities.
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Patients recovering from injury or surgery who require assistance in regaining functional skills.
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Children with developmental delays or disabilities that impact their daily functioning.
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Elderly individuals experiencing age-related challenges that affect their independence.
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Anyone seeking to improve their quality of life through enhanced occupational performance.
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Occupational therapy initial evaluation is a comprehensive assessment conducted by an occupational therapist to determine a patient's functional abilities, therapy needs, and goals for rehabilitation.
Occupational therapists who are providing services to patients are required to file the initial evaluation.
To fill out the occupational therapy initial evaluation, collect relevant patient information, perform assessments, and document findings and recommendations clearly in the evaluation form.
The purpose of the initial evaluation is to establish a baseline of the patient's capabilities, identify areas for improvement, and create an individualized treatment plan.
The initial evaluation must report the patient's medical history, current condition, assessment results, functional limitations, and therapy goals.
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