Instructor’s Manualm3.wyanokecdn.com/860b915e82b7a10f5f62fde64ae0f975.pdfInstructor’s Manual 15 LAC Incorporated 2017 ateley . orcherding 2017) Documentation manual for occupational

Crystal a. Gateley, PhD, Otr/lAssociAte chAir & AssociAte teAching Professor

DePArtment of occuPAtionAl therAPyuniversity of missouri - school of heAlth Professions

columbiA, missouri

sherry BOrCherDinG, Ma, Otr/lclinicAl AssociAte Professor, retireD

university of missouricolumbiA, missouri

Instructor’s Manual

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Copyright © 2017 by SLACK Incorporated

Dr. Crystal A. Gateley and Sherry Borcherding have no financial or proprietary interest in the materials presented herein.

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Instructor’s Manual 3

© SLACK Incorporated, 2017. Gateley, C. A., & Borcherding, S. (2017). Documentation manual for occupational therapy: Writing SOAP notes (4th ed.). Thorofare, NJ: SLACK Incorporated.

IntroductIonThe material contained in this Instructor’s Manual is intended to provide the instructor with ideas and additional

resources for use in conjunction with Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition. Like the textbook itself, the material presented in this Instructor’s Manual has been developed for use in a course on clinical reasoning and documentation. The textbook and these supplemental materials may also be useful in Level I Fieldwork and other courses in your curriculum. The instructional materials presented here may be edited or adapted according to the needs of the individual course, instructor, and occupational therapy program.

WorksheetsThe textbook is intended to serve as a workbook for the occupational therapy student. Numerous worksheets are

provided throughout the book, and suggested answers are provided in the Appendix. It has been our experience that the worksheets function best as in-class activities after the student has reviewed the corresponding chapter prior to class. The worksheets can be completed individually, in pairs, or in small groups and then reviewed as a whole class.

Worksheets can be assigned as homework, but our students have admitted at times to just “copying the answers from the back of the book.” Since learning the skill of documentation takes practice and clinical reasoning, we have found it more beneficial to have students complete the worksheets in class where it is more likely that they will demonstrate a true effort on the worksheets before checking their answers. It is also essential to reiterate to the students that the suggested answers in the Appendix are just one correct way to document. Just because his or her attempt looks very different from the suggested answer does not mean it is wrong.

PuzzlesQuizzes are provided for Chapters 1 through 3 in the form of crossword puzzles. Crossword puzzles are versatile and

easy to change. It takes about 1 hour to create one—less time than a multiple choice test. By adding or deleting a word or two, the entire configuration of the puzzle changes, making it visually very different and thus not very useful for stu-dents to include in a file for future student use. Another advantage of a puzzle is that the length of the word is known, and there are enough overlapping letters to give some hint (as opposed to a fill-in-the-blank question), and yet there is less possibility for successful guessing than in a matching test.

There is free crossword puzzle–making software available for download on the Internet. The program used for this manual is Crossword Hobbyist (The Lesson Builder LLC), which is not free but is very inexpensive (~$20 for unlimited use) and has the advantage of having a person available to answer questions within 1 day—a real plus if you are learning new software.

4 Instructor’s Manual


Chapter 1: Documenting the Occupational Therapy Process



If you prefer, you can use the same words and clues to make a matching test. Just add a word or two as a distractor in the word list, mix up the words or the clues, and you have the same quiz in a form that is more familiar to students, and also quite a bit easier. How difficult do you want to make your test? If you are going for memorization, you’ll want a more difficult test. If you want familiarization, you’ll want to go with something easier.



ACOTE The council that publishes accreditation standards for educational programs in occupational therapy

AOTA Membership organization for occupational therapy practitionersCONTEXT Another word for the social and physical environment in which occupations occurDOMAIN The section of the OTPF-III that outlines the purview of occupational therapy and the areas in

which practitioners have expertiseCLIENT FACTORS Specific capacities, characteristics, or beliefs that reside within the person and that influence per-

formance in occupationsGUIDELINES Publications that provide descriptions, examples, recommendations, and procedures pertaining to

occupational therapy practice and educationPERFORMANCE SKILLS

Goal-directed actions that are observable as small units of engagement in daily life occupations

ICF The World Health Organization publication that provides a common language and framework for health and disability

OCCUPATIONS The daily life activities in which people engagePERFORMANCE PATTERNS

The habits, routines, roles, and rituals used in the process of engaging in occupations

POSITION PAPERS Publications that present the official stance of AOTA on a particular issue or subjectPROCESS The section of the OPTF-III that focuses on the delivery of occupational therapy services, including

evaluation, intervention, and targeting of outcomesOCCUPATIONAL PROFILE

The client’s prior experiences, daily living patterns, interests, values, needs, priorities, occupational history, and reasons for seeking treatment

SOAP An acronym for the 4 parts of an entry into the health recordSTANDARDS The minimum requirements of occupational therapy practice



Chapter 2: The Health Record



You can, of course, use the same process of turning the words and clues into a matching or fill in the blank test as demonstrated previously.



Chapter 3: Reimbursement, Legal, and Ethical Considerations







This chapter is very dense with information, introducing over 30 acronyms. Most of the acronyms have been omitted from this puzzle and added to the acronyms found in Chapters 1 and 2 to form a puzzle of their own.







You may not want to use this puzzle as a quiz, unless it is done open-book. There are about 35 acronyms discussed and defined in the first 3 chapters of this book (not including medical terminology). Occupational therapy practitioners use these terms freely and expect the people with whom they are conversing to know what they mean, and sometimes people do know. Most people know what the ADA is, or the AMA, but how many people know what ”OASIS” or “CHIP” mean in the context of occupational therapy? Practicing therapists are unlikely to know all of these acronyms. An occu-pational therapist who has spent the last several years doing early intervention or behavioral health is unlikely to know the acronyms currently used in long-term care. Again, you could change this to a matching quiz, but the most fun thing to do with it would to turn these acronyms into a game of Jeopardy. What is Jeopardy but a quiz? Students are much more likely to remember the terms from an activity that has been fun. Instead of penalizing students who don’t do well, why not just give extra credit to the students that get the most points in the game? We have found that extra credit, even in small amounts, is very motivating to students who came into the program as bright and competitive individuals and who stress easily over losing one or two points on a quiz. If they know in advance that the most successful contestants will get extra credit points, they are very likely to learn picky details with much more joy and grace than they would to pass a test. Later, when they lose a few points on their first SOAP notes, the extra credit points will decrease the lines of students outside your office wanting to negotiate for more points.

QuIzzesBeginning with Chapter 4, there are worksheets for each chapter. A few of the worksheets lend themselves nicely for

use as an in-class quiz to assess comprehension of material presented in the chapter: ◆ Worksheet 4-1: Avoiding Common Documentation Errors ◆ Worksheet 6-2: Evaluating Goal Statements ◆ Worksheet 9-2: Justifying Continued Treatment ◆ Worksheet 11-3: SOAPing Your Note

Short quizzes over the chapters are also a good way to ensure that students have read the material in preparation for class. They are also a nice way to balance out graded student documentation, on which students often lose a few to several points as they are first learning to document. Listed below are suggestions for quiz questions focused on key points from each chapter. Answers are in parentheses.

chAPter 1 ◆ The Occupational Therapy Practice Framework, Third Edition (OTPF-III) is divided into what two sections?

(Domain and Process) ◆ Fill in the blank with the correct term from the OTPF-III:

___________: Daily life activities in which people engage. (Occupations) ___________: Specific capacities, characteristics, or beliefs that reside within the person and that influence per-

formance in occupations. (Client Factors) ___________: Goal-directed actions that are observable as small units of engagement in daily life occupations.

(Performance Skills) ___________: Habits, routines, roles, and rituals used in the process of engaging in occupations. (Performance

Patterns) ___________: Physical, social, cultural, temporal, and virtual aspects that influence occupational performance.

(Contexts and Environments) ◆ What are the two parts of the evaluation process? (Occupational Profile and Analysis of Occupational Performance)

chAPter 2 ◆ What does SOAP stand for? (Subjective, Objective, Assessment, Plan) ◆ Explain what HIPAA is. (Federal law that protects the disclosure of a client’s protected health information) ◆ Explain what FERPA is. (Federal law that protects access of educational records) ◆ List and briefly explain 3 purposes of documentation. (Any of the purposes listed in Chapter 2, including cli-

ent care management, reimbursement, utilization review and management, legal system, quality management, accreditation, education, research, business development, and client access)



chAPter 3 ◆ Identify the part of Medicare coverage for each of the following descriptions:

___________: Covers inpatient care in hospitals and critical access hospitals, SNFs, home health, and hospice. (Part A)

___________: Covers physicians’ services and outpatient care, including occupational therapy. Also covers ser-vices in long-term care when the client does not qualify for other Medicare coverage. (Part B)

___________: Private insurance companies contract with Medicare to provide individuals with benefits through Medicare Advantage Plans. (Part C)

___________: Covers prescription drug costs. (Part D) ◆ Under this model of reimbursement, health care providers are paid separately for each service provided.

(Fee-For-Service) ◆ Under this model of reimbursement, Medicare payments are based on a predetermined fixed amount according to

a patient’s diagnosis-related group. (Prospective Payment System) ◆ ___________: Health insurance program funded jointly by federal government and each individual state to cover

individuals who have limited income. (Medicaid) ◆ What is the name of the document used in each of the following settings to record the plan for client services?

■ School settings for ages 3 through 21 years? (Individualized Education Program or IEP) ■ Early intervention setting age birth through third birthday? (Individualized Family Service Plan or IFSP)

◆ What kind of code is used to classify signs, symptoms, injuries, diseases, and conditions? (ICD-10 code) ◆ What kind of code is used to report services and procedures by health care professionals? (CPT code) ◆ What kind of code is used to identify products and supplies such as durable medical equipment, orthotics, and

prosthetics? (HCPCS code) ◆ What kind of code is used to report functional data for clients receiving outpatient therapy services under Medicare

Part B coverage? (G code) ◆ List two AOTA Official Documents that impact occupational therapy documentation. (Scope of Practice, Standards

of Practice for Occupational Therapy, Guidelines for Supervision, Guidelines for Documentation, Code of Ethics)

chAPter 4 ◆ Show how you should sign your documentation as a student. (Crystal A. Gateley, OTS) ◆ TRUE or FALSE—An incident report should be placed in the client’s health record. (False) ◆ TRUE or FALSE—Errors in a written health record should be corrected using correction fluid over the error and

placing your initials above/beside the error. (False) ◆ Rewrite the following sentence using person-first language: I need to go evaluate the stroke in room 105. (I need to

go evaluate the patient in room 105 who had a stroke.)

Other content in Chapter 4: General Guidelines for Documentation may also be used for quizzes. While it may seem ironic to give college students a quiz on grammar, punctuation, capitalization, and spelling, the authors have observed an alarming trend among students in recent years. Many students do not demonstrate proficiency in these basic writ-ing skills. This lack of proficiency may be due to reliance on word processing programs to identify and correct errors. Regardless of the cause, these deficits have serious consequences for clinical documentation.

We recently kept a list of misspelled words in student documentation over the course of a semester. Unfortunately, Table 4-2: Commonly Misspelled Words in Chapter 4 is only an abbreviated version of that list. Although some students may argue that the content of a note is more important than the presentation, we stand firmly in the belief that error-laden documentation reflects poorly on the student or clinician, the academic institution, the department, and occupa-tional therapy as a profession. With that in mind, it is much better for them to miss a few points in class and learn the correct methods than to go out to a fieldwork site or entry-level position and make those errors.

In recent years, one of the authors has started the first day of the documentation course with an ungraded “spelling test” using this list of commonly misspelled words. Each word is recited, students are asked to write it down, and then they immediately are shown the correct spelling on a PowerPoint slide. This is a great way to get students engaged and to bring their attention to where they currently stand in terms of spelling ability. During the following class session, a graded spelling test is given over the same list of words.



Table 4-3 in Chapter 4 of the text lists several commonly used abbreviations in occupational therapy settings. Although many students will have already completed a course in medical terminology prior to or since admission to your occupational therapy program, this list serves as a nice review and can also be used in whole or part for quiz purposes. It is, however, important to reiterate to students that the list is intended only for use in this specific textbook. Different facilities will have lists of acceptable and prohibited abbreviations. Be sure to let students know what abbreviations you consider acceptable in terms of your assignments to them.

chAPter 5 ◆ List the eight Areas of Occupation from the OTPF-III. (ADLs, IADLs, Rest and Sleep, Work, Education, Play,

Leisure, and Social Participation) ◆ List the two primary parts of a problem statement. (Area of Occupation and Contributing Factor) ◆ Give an example of a functional problem statement using any of the formats presented in the chapter.

chAPter 6 ◆ What is another term for a short-term goal? (Objective) ◆ What does the acronym COAST stand for? (Client, Occupation, Assist Level, Specific Condition, Timeline) ◆ Provide an example of a goal statement with all of the COAST elements present.

chAPter 7 ◆ In an initial evaluation note, the “S” may contain all or part of the client’s ____________ . (Occupational profile) ◆ TRUE or FALSE—It is never permissible to report comments from caregivers and other professionals in the “S.”

(False)

chAPter 8 ◆ The “O” should begin with a statement about the ________________ and ________________ of the occupa-

tional therapy session. It may also include information about the duration of the session. (Purpose and Setting) ◆ What are the two ways to organize information in the “O”? (Categorically and Chronologically) ◆ TRUE or FALSE—It is important to emphasize the treatment media used in the session. (False)

chAPter 9 ◆ What three primary things should be discussed in the “A”? (Problems, Progress, Potential) ◆ Complete the following formula for making an assessment statement: (Contributing Factor)

Impact Ability to Engage in Occupation

◆ TRUE or FALSE—There should be no new data in the “A” that was not already discussed in the “S” and “O.” (True) ◆ The “A” should end with a statement that does what? (Justifies the need for continuing treatment. “Client would

benefit from…”)

chAPter 10 ◆ The “P” should include what three elements? (Frequency, Duration, Purpose of continued therapy) ◆ Explain the problem with using the words “plan to assess” in the “P” of your SOAP note. (Insurance reviewers want

to see that you have moved on to intervention.)

chAPters 11 AnD 12Chapter 11 is a review of the information presented in Chapters 5 through 10. Any of the worksheets in Chapter 11

can be used as a quiz to check for overall understanding of the information presented. For Chapter 12, students need to understand the difference between occupation, activity, preparatory method, and preparatory task from the OTPF-III. Students should be asked to review Chapter 12 in conjunction with the section in the OTPF-III that provides specific examples of each type of intervention (see Table 6 in the OTPF-III; AOTA, 2014). You can use those examples to create



a multiple choice quiz on which students have to identify which of the four types of intervention have been described. For example:

◆ Client practices getting in and out of the bathtub. (Activity) ◆ Client performs therapy putty exercises for hand strengthening. (Preparatory Task) ◆ Client completes morning dressing routine using adaptive equipment. (Occupation) ◆ Client participates in a sensory environment to promote alertness. (Preparatory Task) ◆ Occupational therapist administers electrical stimulation to a client’s weak UE after a stroke. (Preparatory Method) ◆ Client reviews with therapist how to use a bus transportation schedule. (Activity) ◆ Occupational therapist fabricates a splint to be used to decrease carpal tunnel pain during clerical work.

(Preparatory Method) ◆ Client refolds towels from a clean linen cart for the purpose of addressing shoulder ROM. (Preparatory Task)

The movie Turkey Sandwich can also be used for identifying which parts of the therapy session fall into each category. On its face, it is all occupation. What parts of the task fall into another category, and why? Other movies could also be used for this.

chAPters 13 through 16Chapters 13 through 16 serve as a resource to students and new practitioners and are not conducive to quizzing stu-

dents over the information. We have found it helpful to have students locate a relevant article about documentation in occupational therapy or another health profession, read it, and bring a few key points to class for group discussion about how the article relates to information presented in the textbook. Later in this section you will find additional ideas for Chapters 12, 13, and 14.

other AssIgnments

icD AnD cPt coDesDocumentation and billing are inextricably linked. Although ICD and CPT codes are frequently updated, it is useful

for students to become familiar with the use of codes in general as part of their documentation. There are several refer-ence guides, both printed and online, that provide explanations of commonly used codes. The AOTA website (http://www.aota.org) has a section dedicated to coding and billing with links to a variety of resources. Consider having your students determine the appropriate ICD code for a client’s diagnosis and the appropriate CPT code for the services documented.

collAborAtive leArningChapter 3, which is very dense in information, lends itself well to a collaborative learning puzzle. To do this, divide the

chapter into parts and assign a small group of students to each part. Each group will then learn and explain its section of the chapter to the class. If you are familiar with collaborative learning strategies, there are many other strategies that might be used in teaching/learning documentation

meDicAl terminologyChapter 4 offers several worksheets on understanding medical terminology. The students could be asked to generate

sentences such as the ones on the worksheets using multiple abbreviations, and then trade papers to translate these back to common English. Often, this will highlight the value of using only those abbreviations listed in the book.

intervention strAtegiesChapter 12 discusses intervention strategies. If students are in a clinic situation while learning documentation, one

effective learning strategy is to ask students to bring in some non-identifying data for a client they have found to be challenging, and ask for brainstorming help from others in the class to get ideas for possible intervention strategies for this client.

A variation of this is “Create a Client,” in which students as a group create a history, occupational profile, and problem list for a fictional client and then decide as a group where to begin with treatment. This is a good collaborative activity,



and does not require students to be in a clinical setting. Role playing might also be used to provide “intervention” ses-sions for documenting the “S” and the “O.”

correctionsChapter 13 gives the AOTA criteria for documenting different stages of treatment. The students could be given a note

that does not meet these criteria and asked to tell what is missing or incorrect. Again, if this is done collaboratively in small groups, there is less pressure and more fun.

Different PrActice settingsChapter 14 gives the unique aspects of several different practice settings. You might collect forms (charting sheets)

from several different practice settings in your area and get permissions for students to use them for practice. Your authors have found that beginning students get confused by the form itself, and often fill them out incorrectly. After using sheets from 3 or 4 different settings, this confusion clears and confidence increases. The students can be asked to compare or critique the different forms in class as a way of becoming more familiar with the requirements of different settings. As electronic documentation becomes more pervasive, you might consider asking a software vendor to demon-strate electronic documentation to your class (as a Webinar, perhaps).

This chapter also lends itself well to a game of Jeopardy. Asking students to read over the chapter and make up Jeopardy questions is a good way of engaging them in what could otherwise be somewhat boring material. Then the questions can be used in class to play a game of Jeopardy, engaging them again in the material at hand. If you save the questions from year to year, you will end up with a nice array of test questions.

DocumentAtion AssignmentsThere is no better way to learn how to document than simply to practice doing it. In addition to the videos provided

with this Instructor’s Manual, there are other resources available that work well for teaching documentation. For exam-ple, International Clinical Educators (ICE) has an online subscription-based video library that features nearly 200 videos of therapy sessions with actual adult and pediatric patients in various treatment settings including acute care, skilled nursing, outpatient, and home health. Additional information is available at http://www.icelearningcenter.com.

Although observing actual clients or watching videos are the best ways to learn documentation, case studies can also be useful for students to learn how to document problem statements, goals, and intervention plans. Two excellent resources for case studies across patient populations are as follows:

1. Case Studies Through the Health Care Continuum: A Workbook for the Occupational Therapy Student, 2nd Edition (Lowenstein & Halloran, 2015)

2. Cases in Pediatric Occupational Therapy: Assessment and Intervention (Cahill & Bowyer, 2015)Regarding grading, be sure to provide feedback about what the student did well as well as areas for improvement.

Effective documentation is a skill that can seem overwhelming to students when they first begin. Even in the most con-fused, incomplete, or poorly written note, there is usually some small item that is done correctly. Pointing out that one success can be very helpful to a student who is struggling with the material. A star, or a happy face, or a comment of “nice job on this part” or “good job noticing this” or “I like the way you worded this” can be confidence boosters. One might think that by college students would no longer value stickers, or might even find them demeaning; however, in our experience, this is not the case. A full color indicator of something done well is a good way of shaping the behavior you want and can be used very effectively to boost confidence and self-esteem while a difficult task is being learned. If you doubt that your students would want stickers, you can always ask at the outset whether they think the stickers would be fun, or whether the students think they are too mature to enjoy these.

Feedback for a whole note can be given in the form of an “ego sandwich.” To do this, begin with a specific complement on something the student has done well, then give a suggestion of what needs to be done differently and why, then end with something else the student has done well. For example:

I really like the way your opening line in the “S” is specific about why the skill of an OT is needed for this interven-tion session.

I would like to see you be a little less focused on the media in your “O”—perhaps use categories for this information. It might help you zero in on the client factors and performance skills and off the treatment media.

Good job of justifying the need for continuing treatment.



It is also helpful to give feedback freely, but to take off points sparingly. Students can tolerate a lot of red ink if there are not too many points lost. And speaking of red ink, it can be helpful to avoid red for grading, as it has a long history in most people’s minds of indicating that something is “bad” or “wrong.” Grading in any other color avoids tying this particular error to every other error made in this lifetime.

Most students in our professional programs are very high achievers academically, and earning a 7 out of 10 on a SOAP note can seem devastating to a student who is used to getting nothing but As. It is helpful to prepare the class in advance for the likelihood that their first few graded assignments are likely to earn lower scores than what they are used to receiving. Hopefully, their scores will only go up as the semester progresses. Also, tell them that perfect scores on student documentation are rare. There is almost always something that would improve the note. Students need time and feedback to develop a repertoire of professional language/jargon and to figure out a clinical perspective for their client observations. Thus, notes earlier in the course should be graded with more lenience and more feedback than subsequent notes. The opportunities for quiz points and extra credit mentioned earlier can be used to calm students’ fears about getting a low grade in the course; being asked to leave the program; having their lives ruined; and ending up destitute, friendless, unemployed, and homeless all due to the totally unreasonable and unfair loss of two points on this one note. It can also be helpful to tell students that anyone hanging by a point or two between an A and a B will be given an oppor-tunity for earning extra credit points. It is rarely necessary, and is very helpful in alleviating fears.

Another helpful strategy is to keep a running list of errors or suggestions as you grade each set of notes. Chances are that the comments made on one student’s note are likely to be similar to several others since they are all at the same stage of learning how to document. You can use this list to open class discussion during the next class period before handing back the graded assignments. If there is time, also consider rewatching the video so you can point out specific sugges-tions about what should have been documented. Students learn more from feedback when they have a chance to discuss it as opposed to just looking at their scores and moving on.

Depending on how your course is structured, we highly recommend having students complete some of their notes handwritten in class. Our students have reported that they remember and learn more when they write than when they type. Researchers have found evidence to back up this phenomenon (Borelli, 2014). We use a combination of homework assignments, in-class partner or small group work, and individual in-class writing assignments. As the semester pro-gresses, the time students are allowed to complete handwritten documentation in class is reduced from 75 minutes, to 60 minutes, to 45 minutes, to 30 minutes; and yes, early on, they will need that long to write a note. We are asking them to synthesize not only the information presented in this textbook, but also all of the information from previous and concurrent coursework about client conditions, clinical reasoning, and evaluation and intervention strategies.

We also gradually reduce the number of supports they are allowed to use while they document. For the first few notes, they can use all available resources including the book, grading rubric, their own previously graded assignments, and notes they jotted down while watching the video. Later in the semester, they are expected to watch a video without taking any notes and complete a handwritten note in 30 minutes without referring to the book, grading rubric, or previously graded notes. Finally, recognizing that most students will be using some form of electronic documentation, we have them complete the final few notes of the semester on their laptops or tablets, but they are allowed only 10 minutes to complete each note. For this final challenge, we often have them watch a video of a client on whom they have previously documented and received feedback. Initially, students find this progression in expectation daunting, but we consistently get feedback from students that this method was effective in helping prepare students for the realities they will encounter in fieldwork and entry-level practice.

The following pages contain sample assignments that can be used to document treatment sessions from the videos provided with the Instructor’s Manual, other treatment sessions that you have recorded, or for observation of an actual client in a class or fieldwork setting. These can be used as in-class or homework assignments. The following forms and corresponding grading rubrics are provided for you to adapt or edit according to your needs:

◆ Writing Functional Problem Statements ◆ Writing Goals—The COAST Method ◆ Writing an Intervention Plan (2 examples) ◆ Writing a SOAP Note

When students are first learning to document, the process can seem overwhelming. The first two assignments (Writing Functional Problem Statements and Writing Goals—The COAST Method) break down the process into man-ageable steps for the student. The third assignment (Writing an Intervention Plan) combines the concepts of the first two assignments and adds in the requirement for the student to identify interventions to address the client’s problems and goals. Two different formats are provided. The final assignment (Writing a SOAP Note) assesses the student’s under-standing of all the concepts presented in the textbook.


From Gateley, C. A., & Borcherding, S. Documentation manual for occupational therapy: Writing SOAP notes, fourth edition instructor’s manual. © 2017. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2017).

Documentation manual for occupational therapy: Writing SOAP notes (4th ed.). Thorofare, NJ: SLACK Incorporated.

WrItIng FunctIonAl Problem stAtementsName: ___________________________________ Date: _________________________Client: ___________________________________

Identify at least 2 strengths and 2 problems for the client observed. List more if applicable.

Strengths Problems ◆

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◆

◆

◆

◆

◆

◆

◆

◆

For each problem you have identified, write a functional problem statement using one of the three formulas found in Chapter 5:

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grAdIng rubrIc: WrItIng FunctIonAl Problem stAtementsName: ___________________________________

Points Points Possible

Criteria

2 ◆ Professional presentation (typed or black ink), neat, legible, signed appropriately, turned in on time

◆ At least 2 strengths and 2 problems identified ◆ No grammar, spelling, or punctuation errors (0.5-point deduction per error)

4 ◆ Strengths and problems reflect accurately what was reported, observed, or reason-ably extrapolated based on client’s known abilities and limitations.

2 ◆ Wording is clear to the reviewer; each problem is distinct (not two ways of saying the same thing).

2 ◆ Each problem statement contains a clear area of occupation and contributing factor.Total

10Comments:




WrItIng goAls—the coAst methodName: ___________________________________ Date: _________________________Client: ___________________________________

For each problem identified, write at least one long-term goal (LTG) and one short-term goal (STG) for the client using the COAST method:

◆ C—Client Client will perform ◆ O—Occupation What occupation? ◆ A—Assist Level With what level of assistance/independence? ◆ S—Specific Condition Under what conditions? ◆ T—Timeline By when?

Remember that the individual elements of the goal can be rearranged as long as all essential elements are present. Refer to Chapter 6 for additional tips and examples of COAST goals. Use additional pages if necessary.

Problem Statement #1:

LTG:

STG:


LTG:

STG:


LTG:

STG:




grAdIng rubrIc: WrItIng goAls—the coAst methodName: ___________________________________


Criteria


◆ At least 1 LTG and 1 STG for each problem identified ◆ No grammar, spelling, or punctuation errors (0.5-point deduction per error)

3 ◆ Goals are treatable in and appropriate to the clinical situation (outpatient, home health, inpatient, etc.).

◆ Goals are measurable, observable, and realistic to the client and setting.3 ◆ Goals are occupation-based and demonstrate medical necessity (or educational

necessity if appropriate). ◆ Treatment is indicated within the scope of occupational therapy practice and

requires the skill of an occupational therapy practitioner.2 ◆ All COAST elements are present in a manner that emphasizes occupation.

◆ Goals are concise and organized. ◆ Interventions are not used as goals.

Total10

Comments:




WrItIng An InterventIon PlAn—exAmPle 1Name: ___________________________________ Date: _________________________Client: ___________________________________

Develop an intervention plan for your client based on the problems and goals you have identified. For each long-term goal (LTG), you should identify at least two short-term goals. For each short-term goal (STG), you should identify at least two interventions. Be sure that your interventions include an appropriate mix of preparatory methods, purposeful activity, and occupation-based intervention. Refer to Chapter 12 in your textbook for tips and examples. Use additional pages if necessary.

Problem:

LTG:

STG (Objective) Intervention Type of Intervention(Occupation, Activity, Preparatory Method, or Preparatory Task)

STG #1: ◆ ◆ ◆

◆ ◆ ◆

STG #2: ◆ ◆ ◆

◆ ◆ ◆

Frame(s) of reference used:

Problem:

LTG:

STG (Objective) Intervention Type of Intervention(Occupation, Activity, Preparatory Method, or Preparatory Task)

STG #1: ◆ ◆ ◆

◆ ◆ ◆

STG #2: ◆ ◆ ◆

◆ ◆ ◆

Frame(s) of reference used:




grAdIng rubrIc: WrItIng An InterventIon PlAn—exAmPle 1Name: ___________________________________


Criteria


◆ At least 1 LTG and 2 STGs for each problem identified ◆ At least 2 interventions for each STG identified ◆ No grammar, spelling, or punctuation errors (0.5-point deduction per error)

3 ◆ Goals are treatable in and appropriate to the clinical situation (outpatient, home health, inpatient, etc.).

◆ Goals are measurable, observable, and realistic to the client and setting.3 ◆ Goals are occupation-based and demonstrate medical necessity (or educational

necessity if appropriate). ◆ Treatment indicated is within the scope of occupational therapy practice and

requires the skill of an occupational therapy practitioner.2 ◆ All COAST elements are present in a manner that emphasizes occupation.

◆ Goals are concise and organized. ◆ Interventions are not used as goals.

5 ◆ Interventions address the client’s goals and are appropriate to the setting. ◆ Interventions contain an appropriate mix of preparatory methods, preparatory

tasks, activities, and occupations and are correctly identified as such. ◆ Interventions demonstrate clinical reasoning and creativity expected at student’s

current level of professional education. ◆ Appropriate frames of reference have been identified to guide intervention.

Total15

Comments:

* Note: This grading rubric can be modified to include the additional criteria for Example 2 of Writing an Intervention Plan, shown on the next page.




WrItIng An InterventIon PlAn—exAmPle 2Client Name: _____________________________ Therapist Name/s: ______________

LTG (expected function at discharge):STG (must relate to LTG):

Thorough Explanation(What is the setting? What is the set-up? What will the client do? What will the occupational therapist do that makes this a skilled intervention? How would you grade this activity?)

Frame of Reference

Top-Down or Bottom-Up

OccupationActivityPrep MethodPrep Task

CPT Code

Intervention #1:

Intervention #2:




WrItIng A soAP noteName: ___________________________________ Date: _________________________Client: ___________________________________

Write a SOAP note for the client’s occupational therapy session. Remember to include the essential elements for each section of the SOAP Note. Refer to the Quick Checklist found in the back of your textbook.

S:

O:

A:

P:




grAdIng rubrIc: WrItIng A soAP noteName: ___________________________________


Criteria


◆ No grammar, spelling, or punctuation errors (0.5-point deduction per error)1 ◆ The “S” is relevant to the session and is accurate. (If the client is quoted, the quote

contains the client’s exact words.) ◆ The “S” is concise and coherent. The most relevant information has been selected

rather than repeating the client’s history (except for initial evaluation) or listing everything the client said.

3 ◆ The “O” begins with where, for how long, and for what purpose the client received occupational therapy.

◆ The “O” is worded in a way to indicate active client participation. ◆ The “O” demonstrates that the skills of an occupational therapy practitioner were

required. ◆ The “O” contains accurate information with correct medical terminology and

abbreviations. ◆ Assist levels show what part of the task required assistance. ◆ Response to client/caregiver education is noted when appropriate. ◆ Intervention is described in terms of purpose and function, deemphasizing the

treatment media. ◆ The “O” is written from the client’s point of view, using nonjudgmental language.

3 ◆ The “A” contains a complete assessment of the data presented in the “S” and “O.” ◆ Problems, progress, and/or rehab potential are clearly indicated. ◆ No new material is presented in “A” that wasn’t already discussed in “S” or “O.” ◆ The “A” ends with a statement about what the client would benefit from. ◆ There is adequate justification for continued skilled occupational therapy.

1 ◆ The “P” contains information regarding frequency/duration of services and for what purpose the client will be seen.

◆ The “P” contains a description of planned interventions to address the problems identified in the “A.”

◆ The “P” is reasonable for this particular client and setting.1 ◆ Each SOAP category contains only the correct information for that category.

◆ The entire note is complete, organized, and concise.Total

10Comments:



sAmPle vIdeosWe have provided 12 videos that are useful to students in learning documentation. These videos can be used as in-

class or homework assignments. If used in class, students can complete the assignment individually or work in small groups. A brief summary of each video is provided next. A more detailed case history and sample documentation for each video is provided on the pages that follow. Each video was recorded in real time and then edited to take less class time and still show all interventions. Thus a half-hour session may be edited down to an 8- or 10-minute video. You need to decide if you want students to assume that each session was a specified amount of time (e.g., 30 minutes), or if you want them to report the exact number of minutes they saw on the video, which emphasizes ethical reporting from the very beginning of documentation. Both approaches have been used in the sample notes that follow.

◆ Mr. Suzuki (11 minutes)—The client is a 71-year-old man who recently broke his hip. The session takes place in an inpatient hospital setting. The occupational therapist in the video is teaching him how to get dressed using adap-tive equipment.

◆ Mrs. Mulliver (8 minutes)—The client is an 82-year-old woman who has macular degeneration. She has purchased a vision machine to enlarge print so that she will be able to see to read and write independently. The session takes place in her home, and the occupational therapist teaches her how to use the vision machine.

◆ Coach (7 minutes)—The client is a 67-year-old man who injured his knee and is now in a knee immobilizer. The session takes place in an outpatient clinic and in the parking lot outside. In this video, the occupational therapist instructs him on tub transfers and car transfers.

◆ Diana: Turkey Sandwich (9 minutes)—The client is a 55-year-old woman who had a stroke resulting in dense hemiparesis of her dominant right upper extremity. This session takes place in her home and addresses the use of adaptive equipment and one-handed strategies for light meal preparation.

◆ Max: Discharge Day (15 minutes)—The client is a 35-year-old man who sustained a C5 spinal cord injury in a div-ing accident. This session takes place on the last day of a two week Phase 2 inpatient rehabilitation stay and focuses on the client’s ability to direct his personal care attendant in assisting him with transfers and ADLs.

◆ Bill: Wheelchair Clinic (10 minutes)—The client is a 27-year-old male who recently experienced a Multiple Sclerosis exacerbation. He has borrowed a manual wheelchair from a friend to assist him in getting around his busy work environment. This session takes place during a wheelchair clinic to assess and modify his borrowed wheelchair.

◆ Melody (13 minutes)—Melody is a 3-year-old girl who sustained a brachial plexus injury at birth. She had a bra-chial plexus repair but still has deficits in functional movement on her involved side. This session takes place in an outpatient pediatric clinic.

◆ Siobhan (16 minutes)—Siobhan is an 11-month-old infant who sustained a severe head injury in a motor vehicle accident when she was 4 days old. She has complex orthopedic and neurological problems. This session takes place in a Birth to Three Clinic where she is followed periodically to determine developmental progress. Siobhan exhibits seizure activity during this session.

◆ Tom (13 minutes)—Tom is a 48-year-old male with a diagnosis of schizophrenia and a long history of psychosocial interventions. This session takes place in his home as his Case Manager, who is an occupational therapist, assesses his current functional abilities and makes a determination to increase the level of supervision and services he is receiving from his community support center.

◆ Tom’s Progress (9 minutes)—This session, also in Tom’s home, takes place 3 weeks after the previous video. His occupational therapy case manager reassesses his functional status in preparation for writing a progress note and making a recommendation about his level of services from the community support center.

◆ John (20 minutes)—John is a 45-year-old man with a diagnosis of bipolar disorder with OCD and borderline features, self-medicating with alcohol. He has been admitted to an inpatient psychiatric facility following a recent suicide threat. This individual session with the occupational therapist focuses on symptom identification.

◆ John’s Progress (18 minutes)—This session takes place on the third day of a John’s 4-day inpatient hospitalization. This session focuses on identification of coping strategies in preparation for discharge.

These videos are a combination of “staged” situations and actual client treatment sessions. We encourage you to develop similar videos for use in your classroom, particularly videos that cover other occupational therapy settings and specialty areas not represented here. Faculty colleagues, students, and local clinicians are great resources for this type of project. Ideally, you could have an actual “client” come to class for an occupational therapy session and have students document about that session.



We have included sample documentation for each of the videos that may be helpful as you grade student assignments or as an example to show the class when their graded assignments are returned to them. Just as we tell our students, please remember that these samples are not the only correct way to document.

mr. suzuki

HistoryWhen Mr. Suzuki was 18 years old, he immigrated to the U.S. from his native Japan to accept a scholarship to the

University. His culture places a high value on education and has great respect for teachers, so Mr. Suzuki became a high school math teacher. He retired 6 years ago.

Mr. Suzuki values his health, and has always kept himself fit, even as he has aged. At 71, he is still healthy, even though he does not hear as well as he once did, and sometimes misses auditory cues. One day at the Fitness Center, he stepped onto a treadmill without realizing that its user had left it running and gone to the bathroom. Mr. Suzuki fell and broke his hip.

He was admitted to Lewis and Clark Hospital for a total hip replacement. The hospital uses a critical care pathway for hip replacements, which calls for a 3- to 4-day length of stay with specific interventions for each discipline (see Table 12-1 in your text). This is postoperative day 2 of the program.

Mr. Suzuki is embarrassed by the idea of being seen using a walker. He places great value on saving face, and does not want friends and family to see him limping. His granddaughter is getting married in 3 months, and he plans to walk her down the aisle in her father’s place. He is motivated to work hard to return his body to a state of fitness in order to walk normally again.

Sample DocumentationProblem #1: Client requires adaptive equipment and verbal cues to complete lower body dressing due to hip precautions.

LTG: By discharge in 2 days, client will complete lower body dressing with modified independence using adaptive equip-ment and maintaining all hip precautions.

STG: Client will don pants with SBA using dressing stick by tomorrow’s ADL session.

STG: Client will don socks and shoes with modified independence using adaptive equipment by tomorrow’s ADL session.

Problem #2: Client requires verbal cues follow hip precautions during ADLs due to unfamiliarity with the hip precautions.

LTG: By discharge in 2 days, client will complete all basic ADLs with modified independence while demonstrating com-pliance with hip precautions.

STG: Client independently will verbalize 3/3 hip precautions for safety during ADLs by next treatment session.

STG: Client will complete grooming tasks standing at sink with walker with no more than 1 verbal cue for hip precau-tions by tomorrow’s ADL session.

STG: Within 2 sessions, client will complete toileting with using commode frame and walker with no more than 1 verbal cue for hip precautions.

Students often want to attribute the client’s inability to recall the hip precautions to a “cognitive deficit” or “decreased short-term memory.” This is a good opportunity to point out that a client’s unfamiliarity with the new “rules” he has been given is simply due to a lack of experience with this situation, not a lack of intellectual ability. Additionally, some students document the contributing factor as “due to THR.” This is an opportunity to remind students that the diagnosis is not the contributing factor. In this case, it is the postsurgical restrictions that have been imposed on the client.

Some students have difficulty coming up with other goals since the video focuses very specifically on lower body dressing. This is where clinical reasoning comes in. Ask the students questions like, “Based on what you know about Mr. Suzuki, what other problems might he be having?” or “What areas of occupation are impacted by his deficits?” Also refer them again to Table 12-1, which lists the clinical pathway for a total hip replacement, but remind them that the table lists interventions, not necessarily occupation-based goals. Other possible LTGs include the following:

◆ By discharge, client will complete grooming tasks standing at sink using walker with modified independence, following all hip precautions.

◆ By discharge, client will complete bathing with modified independence using tub bench and long-handled sponge, following all hip precautions.

◆ By discharge, client will demonstrate transfer in/out of car with modified independence while adhering to hip precautions.



We have also encountered several students who want to write goals for ambulation since walking is heavily empha-sized in the client’s history. Occupational therapists very often encounter clients who respond, “I want to walk” when asked regarding personal goals, but the physical therapist will be addressing ambulation. This video is a good oppor-tunity to discuss issues such as occupational therapy’s domain and duplication of service with other disciplines. It also presents students with the opportunity to learn to focus on occupation, while still addressing the issue of safe ambulation during occupational performance. For example, consider these goals for Mr. Suzuki:

◆ By discharge, client will retrieve clothing from closet with modified independence using walker for safety during ambulation.

◆ Client will prepare a snack in rehab kitchen with SBA using walker and wheeled cart for item retrieval and transport within 2 treatment sessions.

Here is an example of a SOAP note for Mr. Suzuki:

S: When asked, client was able to state 1 of 3 hip precautions.

O: Client participated in 30-minute bedside OT session for skilled instruction in compensatory techniques for lower body dressing following Ⓡ THR. Client was seated EOB upon therapist’s arrival, having just finished bathing with nursing staff. Pt. appears to have full function of his upper extremities and is limited primarily by his postsurgical hip pre-cautions. After set up, client donned socks using sock aide with min Ⓐ for hand positioning and to thread sock onto device. Client donned pants with min Ⓐ and verbal cues to position dressing stick. Verbal cues required to don shoes using long shoe horn. Client required 3 verbal cues to follow hip precautions during lower body dressing. Client able to sequence dressing tasks Ⓘ and spontaneously demonstrated problem solving to retrieve hard to reach items using reacher. Client completed upper body dressing tasks with modified Ⓘ from EOB.

A: Inability to recall 2/3 hip precautions raises safety concerns in ADLs, IADLs, and functional mobility. Inability to remember all hip precautions and correct use of adaptive equipment necessitates assistance and verbal cueing to dress lower body safely. Ability to remember one hip precaution shows progress. Ability to sequence task and problem indicates good potential for return home with modified independence. Client would benefit from continued skilled instruction in hip precautions and adaptive equipment/techniques in ADL tasks as well as IADL tasks.

P: Continue OT bid for 30 minute sessions for 2 more days to increase ability to follow hip precautions in ADL and IADL tasks. OT to address dressing, toileting, bathing, snack preparation, and car transfers by discharge.

mrs. mulliver

HistoryMrs. Mulliver is an 82-year-old woman who has macular degeneration, resulting in low vision. She lives at home

with her 85-year-old husband, who also has a disabling condition (CVA 6 years ago). The Mullivers were childhood sweethearts and have been married for 61 years. They have 3 grown children and 5 grandchildren. Dr. Mulliver has been successful in his career as a surgeon and the Mullivers are comfortably well-off financially.

As Mrs. Mulliver’s vision has worsened, she has become less and less independent in her IADL activities. She loves to cook, but can no longer read recipes or packages. She has always been the one to manage the family finances, but she can no longer see well enough to write a check. Dr. Mulliver is willing to help her, or to take over some of the roles and tasks that have always been hers, but Mrs. Mulliver values her independence and her ability to make a contribution to the household. She wants to be able to continue with some of her most prized roles.

The Mullivers have ordered a Spectrum III machine to enlarge print so that Mrs. Mulliver can read it. When it was delivered earlier in the week, Dr. Mulliver called the local Home Health Agency to request that an occupational therapist come out and teach his wife how to use the new machine. The Mullivers have received services from the Home Health Agency in the past, and are acquainted with the agency. They are private-pay clients, and there is no concern about what is covered under Medicare.

Laura is the occupational therapist who will be visiting Mrs. Mulliver today. She is a recent graduate who began work-ing for the agency a few months ago. She is acquainted with the Spectrum III and has reviewed its functions to be sure she will be able to teach its use easily. She is a little nervous because she has never met the Mullivers and wonders what they will be like.

Sample DocumentationThis occupational therapy session is unique in that funding justification is not an issue as this is a private-pay client.

Also, based on the interaction at the end of the video, we know that the occupational therapist plans to see the client



just one more time after this. This is a great opportunity to explain to students that occupational therapy evaluation and intervention often overlap. The occupational therapist in this video is assessing the client’s performance while she is instructing her in the use of the vision machine. For purposes of documentation, it may be helpful to stop the video after the first 45 seconds and have the students write a problem statement, one long-term goal for the next session, and a few short-term goals for the existing session, then have the students watch the remainder of the video and write a SOAP note.

Problem: Client requires visual enlargement tool to read and write small print needed for home management tasks 2° to low vision.

LTG: After 2 treatment sessions, client will complete IADL activities involving small print with modified Ⓘ using the Spectrum III print enlargement machine.

STG: After 1 treatment session, client will be able to read a recipe using the Spectrum III with min verbal cues for use of machine features.

STG: After 1 treatment session, client will be able to locate a number in the phonebook using the Spectrum III with min verbal cues for machine features.

STG: After 1 treatment session, client will be able to write a check using the Spectrum III with min verbal cues for machine features.

S: Client reports having difficulty reading small print. She would like to be able to find numbers in the phone book, read recipes, and write checks independently. At the end of the session, she reported finding the Spectrum III very helpful in reading and writing.

O: Client participated in 30-minute OT session in her home for skilled instruction in the use of the Spectrum III print enlargement machine for reading and writing tasks during IADLs. Client’s primary deficit is limited visual acuity related to macular degeneration. Following instruction in machine features (focus, color, brightness, size, and under-line), client demonstrated ability to read a recipe and a number from the telephone directory with min verbal cues for use of machine features. Client also wrote a grocery list and a check with min verbal cues for use of machine features.

A: Low vision impacts client’s ability to read and write during IADL tasks. Ability to use Spectrum III with min verbal cues during today’s session shows good progress toward stated goals. Client shows good potential to be independent in reading and writing any print item that can be placed in the Spectrum III. Client would benefit from one more visit to reassess independence with use of machine and instruct further as needed.

P: Client to be seen for one more intervention session in 1 week to assess knowledge and understanding of the Spectrum III. Independence with reading and writing tasks using the Spectrum III during IADLs will be reassessed and addi-tional skilled instruction provided as needed.

coAch

HistoryJohn Darling is a 67-year-old white male who coached high school sports for 41 years prior to his retirement 2 years

ago. Since the name “Darling” was a major source of amusement for high school students, he started going by the name “Coach” early in his career. After a few years, even his family and friends began to call him “Coach,” and it became his identity. Although retired, he still loves sports and young people, and now volunteers to coach a team of disadvantaged youth in Two Mile Prairie, about 25 miles north of his home town.

On Saturday, he was demonstrating a play when he stepped in a hole and was hit from the side, landing underneath two of the larger boys. Coach ended up with a spiral fracture of the distal femur of his right leg.

He was taken to Two Mile Prairie General Hospital, where an ORIF (open reduction internal fixation) was done on an emergency outpatient basis. He was sent home with pain medication and a knee immobilizer and told not to bear weight on his right leg for 3 to 4 weeks. He took the pain medication and slept most of Sunday. First thing Monday morning, he called his primary care physician. Knowing she was wasting her breath, the PCP nonetheless lectured Coach on what a 67-year-old man should and should not be doing as it pertains to football. She scheduled an appointment to see him on Thursday and ordered outpatient occupational therapy and physical therapy (2 to 3 visits each) to get Coach some education on proper ways to maintain his nonweightbearing status and also to get him started on a good home exercise program.



Suzanne, the occupational therapist, and Mark, the physical therapist at Two Mile Prairie Outpatient Therapy, have worked together for several years and work well together. Mark saw Coach this morning to fit the walker and teach Coach how to use it properly. He will be doing some gentle PROM and starting Coach on a home program of strengthen-ing exercises as healing progresses. He plans to ask for more visits to work on ambulation when Coach is ready to begin some weight bearing

When Suzanne asked Coach what his priorities were, his first two priorities were to be able to take a bath and to be able to get in and out of the car. The physician told him that he could take off the immobilizer after he was sitting in the bathtub, and that he could take it off in physical therapy, but otherwise he was to wear it 24/7. Since Coach cannot reach his feet, he will need some adaptive equipment and techniques for dressing also, but Suzanne plans to start with tub and car transfers since that is what Coach wants to do most. His wife has taken 1 week off work to take care of him this first week, and she has been helping him with things like dressing.

Sample DocumentationThis video is another example of intervention beginning during the first session. Based on the information provided

in the client’s history, we can assume that the occupational therapist in this video has already completed a brief evalua-tion and identified the priorities for intervention.

Problem #1: Client unable to get in and out of tub and car safely and independently due to NWB status and inability to bend Ⓡ knee with immobilizer.

LTG: Within two sessions, client will complete tub and car transfers with modified independence using adaptive equip-ment and techniques.

STG: By the end of the first treatment session, client will complete tub transfer with SBA using tub transfer bench.

STG: By the end of the first treatment session, client will complete car transfer with SBA using adaptive techniques.

S: Client reports difficulty getting in and out of the bathtub and car.

O: Client participated in a 30-minute OT session in outpatient clinic for skilled instruction in safe transfers for ADLs and IADLs. Pt. presents with knee immobilizer on Ⓡ LE and is able to ambulate using walker with mod Ⓘ while maintaining NWB for Ⓡ LE. Following instruction in sit/scoot/pivot method, client demonstrated understanding by repeating instructions and perform tub transfer x2 with SBA using tub transfer bench. Min verbal cues were required for safe hand placement on tub bench. Using same technique, client transferred walker ↔ car with SBA, using plastic bag to facilitate scooting on seat. Min verbal cues required for adaptive technique and safety. Client also required assist to move walker following both tub and car transfers.

A: Ⓡ LE NWB status and inability to bend Ⓡ knee due to immobilizer limit client’s ability to transfer in and out of tub and car independently and safely. Same deficits also impact client’s independence with dressing tasks. Progress with transfers in today’s session and quick skill acquisition indicate excellent rehab potential. Client would benefit from reassessment of independence with transfers and skilled instruction in use of adaptive equipment and techniques for lower body dressing.

P: Client will be seen 1 more 30-minute session to reassess safety and for skilled instruction in lower body dressing. Session will focus on skilled instruction and trial use of adaptive equipment including reacher, sock aid, dressing stick, and long shoe horn.

Although this video focuses specifically on functional transfers, students should be able to use their clinical reasoning skills and the information from the client’s history to identify lower body dressing as another problem area to be tar-geted for intervention. The physician wrote orders for 2 to 3 visits of occupational therapy, but based on the client’s fast progress in this session, it is likely that he will be able to master the use of adaptive equipment for lower body dressing in just one session. Therefore, only a long-term goal is necessary for this problem.

Problem #2: Client requires assistance from caregiver for lower body dressing due to Ⓡ knee immobilizer and NWB status.

LTG: Client will complete lower body dressing with modified independence using adaptive equipment by end of next session.



DiAnA: turkey sAnDwich

HistoryDiana is a 55-year-old married White woman who lives with her husband, Joe. She has 2 adult children, neither living

in her home. For the past 22 years, Diana has been the office manager at her husband’s construction company, where she answers the phone; does the bookkeeping; and responds to customers, suppliers, and 20 employees. She has been active in her church, where she has been very involved in the youth groups. She is outgoing and very creative and enjoys taking care of her home, her family, and her husband’s business.

Five weeks ago, Diana was standing in her kitchen when she began to feel “weird” and fell to the floor, unable to speak. She was taken to Two Mile Prairie Hospital, where she was diagnosed with a cerebral vascular accident resulting in right hemiplegia and expressive aphasia. She was hospitalized for 3 days in acute care at Two Mile Prairie General Hospital, and then transferred to Two Mile Prairie Rehabilitation Center for an additional 2 weeks of rehabilitation (occupational therapy, physical therapy, speech, and psychological services). She was discharged home 1 week ago and is now receiving home health services, which include occupational therapy.

Diana has no active motion in the right upper extremity. She has a manual wheelchair, which she uses for mobility, although she is able to ambulate with a quad cane for short distances. She wears an AFO on her right lower extremity to counteract foot drop. She was formerly right handed. Her inpatient occupational therapy treatment focused on increas-ing independence in basic ADL tasks and maintaining passive range in the right UE in hopes of getting some return in that UE. She is able to complete BADL tasks after set up except for pulling up her elastic waist pants, and wants to begin working on IADL tasks now that she is home. Her goal is complete functional independence in BADL and IADL tasks. She hopes to resume her responsibilities at Carter Construction eventually, although her niece has taken over those duties for the present. She also hopes to be able to drive again. Her occupational therapist is not optimistic that Diana will be able to meet all of those goals, but she is working with Diana to get as close as possible to what she wants.

A home evaluation was already completed, and Diana’s husband immediately carried out the recommended safety modifications. In conversation with Diana’s family members, the occupational therapist noted that they were very sup-portive and protective, and seemed to want to do everything for Diana. Knowing that Diana’s goal is independence, Diana and the occupational therapist decided to begin with simple meal preparation in today’s visit.

Sample DocumentationThis video is particularly good for generating a discussion of assist levels. The occupational therapist in this video

wanted to be sure her client had a positive first experience in cooking at home. In trying to ensure success, she may have given more assistance than was required. This is common with beginning therapists and makes for good class discussion about when to wait for the client to figure things out and when to intervene. Here are some other questions for discussion:

◆ What skilled occupational therapy services did you observe? ◆ What compensatory skills were taught? ◆ What adaptive devices were used? ◆ What assistance was needed? ◆ List several cooking activities that would be appropriate to work on next. ◆ What other adaptive devices might be useful for this client? ◆ What might the occupational therapist have done differently during this intervention session? ◆ Do you feel that the client is capable of doing more during this activity than you observed? ◆ What interventions would be indicated for the next session. ◆ Did the occupational therapist offer adequate positive reinforcement?

Problem: Dense Ⓡ UE hemiparesis secondary to CVA results in decreased independence in light meal preparation.

LTG: Within 2 weeks, client will complete meal preparation in standing with modified Ⓘ using adaptive equipment.

STG: By the end of next treatment session, client will cut vegetables with modified Ⓘ using adaptive cutting board and using Ⓡ UE as a functional assist to stabilize items.

STG: Within 1 week, client will demonstrate item retrieval and transport in kitchen during cooking tasks with SBA using quad cane and rolling cart.

STG: Within 1 week, client will complete stove-top cooking task in standing with no more than 2 verbal cues for safety awareness.



S: When asked, client indicated that she has not been preparing her own meals since she has been home, and would like to make a sandwich today. When she was unable to open the mustard jar with one hand, she put it aside and said she didn’t much like mustard anyhow.

O: Client participated in a 9-minute meal preparation activity in her own kitchen for instruction in using adaptive equipment and compensatory techniques. Pt. has no active movement of her dominant Ⓡ UE. She was able to ambulate into kitchen with modified independence using a quad cane and to stand at refrigerator to retrieve items needed, and at the sink to wash vegetables. She sat at the kitchen counter to assemble the sandwich. Client needed min assist for stabilization of the package to remove turkey, position tomato on adapted cutting board, and use a sliding motion with the knife. Adaptive equipment (cutting board with nails and nonslip mat) was introduced and client was instructed in its use. Client able to use the equipment correctly and nodded to indicate understanding of the instructions given. Able to complete all parts of the task safely with verbal cues to use the new equipment correctly and stand-by assist for safety. Education in energy conservation provided and client nodded to indicate understanding.

A: Inability to use the involved UE as a functional assist limits independence in bilateral activities such as meal prepa-ration and other IADL and home management tasks. Limited repertoire of strategies for accomplishing tasks one handed limits her confidence in her own ability to solve problems (such as the mustard jar). Successful completion of the task, apparent understanding of energy conservation suggestions, and correct use of adaptive equipment after demonstration all indicate potential for meeting her goal of making simple meals independently. Client would benefit from additional experience in meal preparation emphasizing safety, use of the involved extremity as a functional assist, and variety of meal preparation tasks.

P: Continue to engage client in meal preparation activities weekly for 2 weeks for instruction in safe use of appliances, and use of adaptive equipment as she gains an increased repertoire of problem solving strategies and gains confidence in preparing simple one-person meals. Next week, safe use of the stove will be introduced in making scrambled eggs. Functional use of the involved UE will be included in future cooking tasks. Advance to other IADL activities if time permits.

mAx: DischArge DAy

HistoryMax is a 35-year-old male construction worker who sustained a C5 spinal cord injury in a diving accident. He

was taken to North County Memorial Hospital by helicopter. After 2 weeks in ICU and acute care at North County Memorial, he was transferred to Lewis and Clark Rehab Center where he received occupational and physical therapy 7 days/week. During Phase I of his rehabilitation, he was stabilized medically and was able at discharge to be up in his chair for 6 hours.

After 3 weeks, he was discharged home using a manual wheelchair to live with his parents. During his stay with his parents, he applied for funding for assistance with independent living in order to fund a personal care attendant (PCA) and a power wheelchair. While he was waiting for the funding to be approved, he also went with his parents to look at accessible apartments. Within the next year, he also plans to apply to vocational rehabilitation for funding to return to school to pursue a less physically demanding vocation.

Max was readmitted to Lewis and Clark Rehab Center for the next phase of his rehabilitation, and has been there for 2 weeks (14 days). His goals for Phase 2 of his rehabilitation were to strengthen his biceps (grade 3+ on admission) and upper trapezius (grade 4 on admission), to learn to direct a caregiver in the areas where he is still dependent, be fit-ted with and learn to use a power wheelchair, and determine the best mode of computer access for him. The treatment team also wanted Max to become very aware of the need for pressure relief in bed and chair, and to direct his caregiver accordingly. Max is at risk for orthostatic hypertension, autonomic dysreflexia, and the development of decubitus ulcers.

He has been fitted with a permanent power chair, his need for bathroom and feeding equipment has been assessed and the necessary equipment has been provided and customized to his needs. Max can feed himself with ball bearing feeders, but he has decided he does not want to use these at home. A home exercise program has been taught to him. He is now able to assist with upper body dressing, feeding and grooming. His biceps strength has increased to a grade of 4 and his upper traps to a grade of 4+. Although he is still dependent in bed mobility and positioning, he is able to direct his caregiver and to remember that he needs to change positions often enough to prevent pressure sores.

He has worked with several occupational therapy staff, but Mohammed has been his primary therapist and is the occupational therapist Max most enjoys working with. Max has told Mohammed that he is very pleased with the occu-pational therapy services he has received during his stay.



Although Max’s parents would prefer that he move back home to live with them permanently, Max is determined to live independently. Since the time he moved out of his parents’ home at age 18 years, he has established his own lifestyle, friends, habits, and preferences and he isn’t willing to trade these for his parents’ lifestyle instead, as much as he appreci-ates their help and their love and concern for him.

Max is in a phased rehab program, where his length of stay this time has been 14 days. He has received occupational therapy twice daily, 7 days per week, in the morning for ADL and IADL training and in the afternoon for strengthening, functional mobility, and positioning. Mohammed has done a home visit (with Max) to Max’s new apartment to evaluate it for accessibility and safety, and has made a few suggestions for home modifications. Mohammed still has some ques-tions about computer access, appropriateness of all equipment in the context of Max’s own apartment, status of the sug-gested home modifications, and a possible need for further caregiver training. He wonders whether these things might be taken care of by a home health visit after discharge. He might also want to recommend a follow-up with Vocational Rehabilitation, and contact with North County Family Resources to investigate available services. Max is ready for dis-charge, and is both excited and apprehensive about trying to live independently. He has rented an accessible apartment and has hired a young woman named Kim as his PCA. Kim is a small woman, and although she says she is strong and is confident that she can do the job, Max is concerned about her ability to transfer a man his size safely. This is discharge day for Max. His new PCA is attending occupational therapy with him to learn how to do transfers properly.

Sample Documentation Problems:

◆ Inexperience in directing personal care attendants limits safety in ADLs, functional transfers, and ability to live alone. ◆ Anxiety and inexperience with adaptive techniques for ADLs limit client’s confidence in his ability to live alone in an

apartment. ◆ Activity tolerance of less than 30 minutes without rest breaks is insufficient for goal of returning to school.

Discharge Goals: ◆ By discharge, client will demonstrate ability to instruct caregiver in performing safe transfers and positioning accord-

ing to his specifications. ◆ By discharge, client will be able to perform all anticipated ADL activities with the assistance of a caregiver, demon-

strating modified independence in instructing caregiver on how to assist him. ◆ By discharge, client will engage in 60 minutes of leisure activity while seated in his power w/c without rest breaks.

Discharge notes, as noted in Chapter 13, are summaries of the interventions provided and changes in a client’s abil-ity to engage in meaningful occupation. Goals are reviewed and noted as met, changed, or continued in another form (follow-up care). They are written very much like progress notes, except that they summarize the entire length of stay. They are often written in a format provided by the facility, but for purposes of this manual, a SOAP format will be used.

S: Client states he is both excited and apprehensive about trying to live independently. Client stated he can breathe easier when positioned correctly, and that he is concerned about his PCA’s ability to transfer and position a man his size.

O: Client participated in occupational therapy sessions 2x/day for 7 days per week for a total of 2 weeks at Lewis and Clark Rehab Center. Pt. presents with C5 SCI and had limited functional use of his Ⓑ UEs. Sessions addressed ADL and IADL training, strengthening, endurance, functional mobility, and positioning.

Admission DischargeBiceps: 3+/5 Biceps: 4/5Upper Trap: 4/5 Upper Trap 4+/5Activity Tolerance (seated): 26 minutes Activity Tolerance: 90 minutes without rest breaksMobility: Dependent in manual chair Mobility: Modified independent in power chair Transfer: Dependent Transfer: Independent in providing caregiver instructionPressure Relief: Dependent in manual chair Pressure Relief: Independent using tilt feature on power chair and

caregiver instructionADLs: Dependent ADLs: Maximum AssistBed Mobility: Dependent Bed Mobility: DependentCaregiver Instruction: Dependent Caregiver Instruction: Independent



Home modifications, computer access, vocational rehab, and services through North County Family Resources, and care giver training were discussed. Client’s PCA demonstrated correct transfers and ability to position him.

A: Tetraplegia resulting from C5 SCI limits client’s independence with ADLs, functional transfers, and educational participation. Ability to provide caregiver instruction in transfers and ADLs indicates good progress toward goal of living alone. Improved strength in biceps and upper trap are good indications for future improvements in ability to participate in desired functional activities. All goals have been met except for determining computer access. Client ready to be discharged from rehabilitation program but would benefit from home health assessment and referral to community agencies.

P: Client will be discharged today from inpatient rehabilitation. Client to continue strengthening program at home. Home health visit recommended to assess the appropriateness of home modifications, adaptive equipment, and pos-sible need for further caregiver training. Vocational Rehabilitation and North County Family Resources should be contacted by client.

bill: wheelchAir clinic

HistoryBill is a 27-year-old male who was diagnosed with multiple sclerosis (MS) at age 20 years. He has the relapsing-remit-

ting type of MS and experiences symptoms of fatigue, numbness, muscle weakness, and impaired balance. Bill works for a large corporation as a media consultant. His job requires him to be in many parts of the building each day, and his symptoms are making that much walking difficult. When his latest exacerbation occurred, he borrowed a wheelchair from a friend to see whether it would conserve energy to use a chair, but he is not satisfied with the current amount of energy he is conserving. He comes to wheelchair clinic today to see if there is some way to make the chair more useful.

Sample Documentation Problems:

◆ Client unable to fit wheelchair comfortably under desk at work due to 19” seat to floor height. ◆ Client reports difficulty propelling wheelchair at work with feet due to inadequate heel strike.

Goals: ◆ Client will report ability to fit w/c under desk for improved work performance by follow-up visit in 1 to 2 weeks. ◆ Client will report increased energy and comfort when using wheelchair for mobility at work by follow up visit in 1 to

2 weeks.

S: Client reports a steady decrease in strength and ability to get around his office since recent exacerbation of illness. He states that he borrowed a wheelchair from a friend about 1 week ago to conserve energy, but that “something’s not right” with the chair. It doesn’t fit under his desk, and he has trouble propelling it with his hands and feet.

O: Client participated in wheelchair clinic for 30 minutes to address wheelchair positioning and mobility at work. Client presents in standard width manual w/c with Ⓑ feet touching floor only at toes and heels approximately 2” off floor. Client demonstrated current tip-toe and arm propulsion technique. Measurement of w/c reveals that seat to floor height is 19 inches excluding cushion. Client educated on a variety of seating options, including a thinner cushion, drop seat, and adjustment of chair height/desk height. Client chose lowering seat height by adjusting axle position. Seat to floor height reduced to 17 inches. After adjustment, client demonstrated ability to heel strike during wheel chair propulsion.

A: Fatigue at work interferes with productivity demands of maneuvering a large office complex. 19” seat to floor height decreases client’s ability to fit comfortably under desk and propel his chair with a heel strike. Borrowing a chair and bringing it to clinic for adjustment shows motivation to conserve energy and maintain productivity at work. Client would benefit from a follow up visit to reassess changes made to chair and to adjust it further or discuss other seating options/energy conservation techniques if needed.

P: Client to return to wheelchair clinic for one more visit to re-evaluate effectiveness of adjustment and discuss the need for additional ergonomic environmental changes.



meloDy

HistoryMelody is a 3-year-old child who has a brachial plexus injury. Her birth was difficult, with one shoulder presenting

first instead of the head. For the first year of her life, Melody had no movement in the involved UE. At the age of 1 year, she had a brachial plexus repair using a nerve graft. Although Melody is very functional using her other UE, she still lacks active wrist extension, elbow flexion, and supination on her involved side. She supinates to mid-point and substi-tutes other movements for those she lacks. Her family is very supportive in carrying out a home program.

Melody’s treatment began with weightbearing, getting Melody’s shoulder to support her. Melody’s family and the occupational therapist would like to see Melody be able to don and doff her own shirt (which would require more elbow flexion than Melody currently has), pull up her elastic waist pants (using bilateral UEs), and don/doff her own socks. Because progress is slow, documentation is the key to maintaining services for Melody.

Sample DocumentationHere are some possible questions for class discussion:

◆ What client factors and performance skills were addressed? ◆ What preparatory methods or tasks did you observe? ◆ What was the child’s response to therapy? ◆ What BADLs might be appropriate to work on to facilitate right UE function? ◆ What would be a good short-term goal for BADL? ◆ What would be a good short-term goal for school?

This is a particularly good video to use for teaching the use of categories for writing the “O.” Students are inclined to discuss this kind of intervention session in terms of what the child did with each of the media rather than choosing cat-egories that discuss performance skills and client factors. Pediatric observations in general seem to be easier to write in categories. In this intervention, there are quite a variety of categories that might be used. It is helpful to begin by asking students to generate a list of what the child is working on in order to help the students re-focus off the media and onto client factors and performance skills. For example, today’s list might include:

◆ Weightbearing through the shoulder ◆ Right upper extremity (active) movement

■ Elbow flexion ■ Wrist extension

◆ Hand to mouth ◆ Bilateral UE use ◆ Crossing midline with the involved arm ◆ Reach, grasp, and release with the right hand ◆ Confidence and problem solving

For each of these categories, you might have the students generate at least two other activities that would accomplish the same desired outcome. For example, today she worked on weightbearing through the shoulders by crawling. What might the occupational therapist do next session to work on weightbearing through the shoulders? A worksheet could be created to address each of these areas and provide a space for students to fill in alternate activities, but it is far more effective to have the students generate the categories from watching the video.

This video lends itself well to being used one section at a time—perhaps just the “fishing” activity, or just one of the hand to mouth segments, or one of the activities done in quadruped or prone in order to teach observation skills and to generate additional interventions. Since play is a viable area of occupation for a 3-year-old child, differentiating interventions that are activities and occupations from those that are preparatory tasks can make for an interesting class discussion.

Choosing CategoriesIt would be unusual for a student to identify all 7 of the categories listed previously. It is much more common for a

student to list 3 or 4 categories, and this should be accepted at the student level. As students become more accomplished pediatric therapists, they will be better able to refine their observations. There are no particular categories that are “cor-rect.” Any of the following groups of categories would be typical of student work and would make an adequate SOAP note. As long as the list of categories is adequate to contain the observed data, any configuration of categories is acceptable.



◆ Hand to mouth ◆ Elbow flexion ◆ Wrist extension ◆ Weightbearing ◆ Midline

◆ AROM ◆ Bilateral UE use ◆ Weightbearing ◆ Grasp

◆ Hand to mouth ◆ Gross motor ◆ Fine motor ◆ Facilitation

◆ Gross motor ◆ Fine motor ◆ Self help

You will find a very comprehensive SOAP note on Melody next. It would be unusual for a student to be this complete, and in fact, a practicing occupational therapist would not have time in his or her busy schedule to write such a lengthy note. The task with this note is to decide what to leave out. How could this note be condensed without losing critical information? For example, could some of the categories be combined? How would that help?

Students first learn to be complete in their documentation. Then, they must learn to be concise. The ability to be con-cise as well as complete is a balancing act for most occupational therapy practitioners, particularly in the first few years of practice. There is no correct answer. Each student, or each class, or each group to whom you present this assignment will make slightly different choices, and it is the decision making itself, rather than the end result, that is important.

S: Child responded “I don’t know” when asked how to crawl, and “I can’t” when asked to turn the scooter. Child reported that the vibrator “tickled.”

O: Child participated in a 30-minute OT session in pediatric clinic to increase strength, AROM and functional use of the right upper extremity needed for self care and developmental play activities. In spite of responses of being unable to complete tasks, child was able to do so.Weightbearing: Child able to use right shoulder in weightbearing activities in prone for 1 to 2 seconds with min assist for support and safety. In quadruped activity, child needed verbal cues to lift right arm and flex right elbow while supporting body weight on left UE. In prone (crawling, climbing, and scooter board activities), child used right shoulder circumduction with elbow extension, requiring verbal cues to use the right upper extremity and to distribute weight equally between right and left upper extremities. On one occasion, spontaneously put weight on right elbow for balance. AROM of right UE: Child requires verbal cues and min physical assist to avoid compensating with trunk rotation for lack of voluntary AROM during activities requiring bilateral hand use. Child able to extend wrist ~30 degrees and to flex elbow following vibratory stimulus.Reach/grasp/release: Child able to cross midline with the right UE with verbal cues to avoid trunk rotation or substi-tuting the left UE. Cylindrical and lateral grasp patterns observed. Child able to grasp and release small objects with forearm supination and limited wrist extension. However, limited voluntary wrist extension and weakened grasp noted in the need for multiple tries to grasp some objects and in dropping others. Needs tactile cues to hold objects with forearm prone. Functional use of right UE: Child demonstrates hand to mouth with tactile cues to flex right elbow and verbal cues to remember to use the right arm. Child used several substitution techniques to bring hand to mouth, including trunk substitution, shoulder elevation, and pull of gravity to substitute for active wrist extension. Child spontaneously used right UE as a functional assist for some bilateral activities. Functional use increased with verbal cues. Facilitation: Child temporarily demonstrated increased elbow flexion and wrist extension after facilitation tech-niques, including tapping, vibration, tendon pressure, and direction of pull.

A: Child’s inability to actively flex the right elbow and extend the right wrist impede efficient dressing, feeding, and developmental play. Need for verbal and tactile cues to remember to use the right UE interferes with engaging it in functional tasks. Weakened and limited grasp patterns interfere with play activities and limits ability to grasp items needed for self care and play activities, and prevent bilateral UE use in pulling up elastic waist pants.Limited ability to bear weight through shoulder interferes with functional mobility in gross motor play activities and raises safety concerns in protective responses. Occasional spontaneous use of the right UE as a functional assist and developing ability to cross midline indepen-dently without substitution shows progress toward independence in bilateral tasks such as dressing. Increased elbow



flexion and wrist extension after facilitation also shows progress toward ability to participate in her own self care. Occasional success in hand to mouth pattern and positive response to verbal cues shows good potential for use of right UE in feeding. Ability to correct movement when cued shows great potential for use as a functional assist in dress-ing. Successful completion of tasks she originally indicated she could not do, as well as willingness to try activities she found difficult, sustained attention to task, ability to problem solve, and ability to generalize learning show good potential to benefit from continued OT. Child would benefit from continued skilled OT instruction and facilitation of right upper extremity to increase functional use in developmental play and ADL tasks.

P: Child to participate in OT twice weekly for 45-minute sessions 8 more weeks for further skilled instruction in efficient patterns of UE use, age-appropriate grasp patterns, and facilitation of elbow flexion and wrist extension in prepa-ration for self-care tasks. Weightbearing through right shoulder will continue to be encouraged in order to develop protective responses. Crossing midline without substitution, spontaneous use of right UE as a functional assist, and hand to mouth patterns in right UE are developing and will be encouraged toward consistency.

siobhAn

HistorySiobhan (pronounced “Shi Vohn”) was carried to term and born into water. At 4 days of age, she sustained a head

injury in a motor vehicle accident. Her life hung in the balance for the first few days. Early MRIs showed extensive dam-age throughout the brain, as well as pelvic fractures caused by the buckle of the car seat. Pediatric neurosurgery consult documented an atypical head shape, flattened in the occiput with a bulging of the right parietal and a prominent ridge across the frontal area. There is a widening of the suture between the right parietal and temporal bones. Present MRIs show the damage to be localized on the left, with no apparent brainstem involvement. She was seen by occupational therapy once during her hospital stay, but no treatment was indicated at that time.

She was discharged eating and sleeping normally after a 3-week hospitalization, and was put into a Pavlik harness 24 hours/day, to treat the hip displacement. Initially, there was no movement in the left LE and clonus was present in both LEs. One month later, the clonus had disappeared on the right, and there was movement in both LEs. She received cra-niosacral therapy twice weekly by an osteopath. She was put on prophylactic phenobarbitol. She had a successful surgery to correct the hip displacement, and a surgery to correct the head shape is currently being considered. The phenobarbitol was not effective in controlling her seizures and other medications are being tried.

Siobhan was evaluated at 2 months, 4 months, and 10 months of age. Each time, Sibohan was “fussy” about being handled by the examiner. Recommendations at 2 months and 4 months were for the parents to continue providing a stimulating environment. At 10 months, it became apparent that therapy was indicated, and Siobhan now receives occu-pational therapy, physical therapy, and speech therapy each week. The occupational therapist sees her twice per week in her home. She is also being followed in the Birth to Three Clinic monthly.

Note that although this was a 30-minute treatment session, there are only about 16 minutes of video after editing. It is up to the instructor how to report the time.

Sample Documentation Siobhan’s injuries are extensive and serious. This video is included because Siobhan is an infant, which is an area of

practice that is not as common as the others in this series. Students or inexperienced therapists would be expected to need some guidance the first time they came across a case such as this, and it is suggested that students be assigned to discuss it in small groups rather than working as individuals. A chart of normal development would be useful to help students figure out where Siobhan seems to be developmentally, as well as what a typical developmental picture would be expected for an 11-month-old child.

Students tend to think too distally, often wanting to splint the hand. The therapist in this video is experienced with infants and works with the proximal stability, segmental movement and realignment needed to facilitate functional mobility, visual regard (looking at people and toys), and visually directed reach, which are more developmentally appro-priate. Her mother is very bright and is devoted to Siobhan. Parent education will be critical to this child’s development.

Problems Noted: ◆ “Windswept” look ◆ Trunk asymmetry ◆ Neck control ◆ Does not move segmentally



◆ Hyperextension of back ◆ High tone ◆ Visual tracking

Problem Statements: ◆ Child unable to reach midline bilaterally or roll segmentally due to hyperextension of back and high tone, which

interferes with functional mobility needed for social interaction, feeding and developmental play. ◆ Child unable to maintain body symmetry due to right internal rotation and left external rotation of pelvis, which

interferes with postural stability needed for visual regard and visually directed reach, feeding, and play.Goals:

◆ In order to increase functional mobility during play, child will roll segmentally with max assist from mother at shoul-der and pelvis to initiate movement within 8 weeks.

◆ In order to increase postural stability needed for feeding and play, child will demonstrate ability to maintain body symmetry after positioning for 1 minute within 8 weeks.

◆ By next visit to Birth to Three clinic, child’s mother will demonstrate ability to properly position and maintain posi-tion with child for 5 minutes daily in order to facilitate emerging functional mobility and play skills.

S: Mother reports that Siobhan has completed her scheduled series of hip surgeries and that there were no hip precautions.

O: Infant participated in clinic area ½ hour for treatment of developmental limitations and parent education. Child pres-ents with atypical posture and movement patterns. Child was initially positioned in supine elevated on a pillow and on the therapist’s legs to counteract the tonic labyrinthine reflex. Shoulder retraction on the right was counteracted by manual facilitation. Associated reactions in right LE were counteracted by manual control. In this position, visual regard and visually directed reach were stimulated by social interaction and presentation of toys. As treatment session progressed, child was placed on the mat in supine without elevation with continued support of the scapula and LEs. In this new position, child continued visual regard and visually directed reach activities. At the end of the treatment session, the child successfully reached toward toys when given the opportunity to do so without demonstrating exces-sive head and back hyperextension and with notably less LE movement than was noted prior to tx.

Using Categories to Write the “O”If the therapist were using categories to report this “O,” she might have said:

O: Child participated in a 30-minute treatment session in clinic to address positioning, tone, and bilateral movement patterns. Child presents with developmental delay and atypical posture and movement patterns.Positioning: Child positioned symmetrically @ shoulders and hips. Able to maintain hip position less than 1 minute. Unable to maintain shoulder position without a hand placed behind scapula.Bilateral movement patterns: With max assist to hold shoulder in protraction, child able to reach bilaterally for a toy held at midline just beyond her reach.Tone: Child demonstrated decreased tone when rocking motion used to facilitate relaxation in shoulder girdle. Hyperextension of back decreased as segmental rolling was facilitated bilaterally.Movement: Child was rolled segmentally to elicit independent movement of the upper and lower extremities. Child demonstrated increased relaxation and segmentation after this facilitation.Caregiver education: Mother educated about rationale behind positioning and movement. Mother responded by asking clarifying questions for positioning child at home.

A: Atypical postural alignment and increased tone interfere with ability to reach developmental milestones appropri-ately. There is a potential for normalized postural alignment and decrease in frequency and intensity of LE associated reactions, which will provide important foundations for development of emerging play skills (reaching and grasping) and for activities of daily living (functional positioning for feeding, dressing, and bathing). Child would benefit from continued therapy with goal that movement patterns achieved during therapy session will carry over into natural environment. Mother would benefit from continued parent education in facilitating desired movement patterns in a natural environment.

P: Child will be seen monthly to continue facilitation of normal patterns of posture and movement and to update the home program as the child progresses. Within 1 month, child will demonstrate movement patterns achieved during therapy session in natural environment.



tom

HistoryTom is a 48-year-old White male, never married, with no children. His parents are both in their 80s, and live in

another state, as do his brothers. He receives social security disability. Tom was a senior in college studying philosophy, when he first became ill. He was diagnosed as having bipolar disorder during his first hospitalization, but his diagnosis was later changed to schizophrenia. He has had 9 hospitalizations since he first became ill. For the past 3 years, he has been a client of River Region Community Support Agency, where he has received case management services. During those 3 years, he has not required hospitalization. Tom is on the following medications:

◆ Zyprexa (olanzapine) and Navane (thiothixene hcl) for schizophrenia ◆ Depakote (divalproex sodium) to stabilize his mood ◆ Xanax (alprazolam) for anxiety ◆ Amantadine to counteract the side-effects of the 2 medications he takes for schizophrenia ◆ Lipitor (atorvastatin) for his cholesterol

Tom has previously expressed concerns that the medications make him tired and cause him to gain weight. Last week, he also expressed a concern that the neighbors are talking about him, and that he thinks he needs to stay awake at night to watch for them.

River Region Community Support Center is staffed by a director, 2 OTRs, and 8 COTAs who provide case-manage-ment services, a driver, clerical/support staff, and a Psychosocial Rehab Center (PSR) director. Each client is seen as often as his or her condition warrants, varying from daily if the client is fragile or at risk, to monthly if the client is stable. Caseload varies according to how ill each client on the caseload is.

Anne has been Tom’s case manager for the last year and a half. She has noticed that he is beginning to be less com-municative, and she is fairly certain he is not taking his medications as prescribed. Tom used to attend groups at the PSR, but no longer does. She is concerned about isolation and wants to prevent a possible rehospitalization. Her visit today is to ascertain his present functional abilities, and the impact of his illness on all areas of occupational performance, and then to find a way to increase his independence in occupational performance if necessary. Since his treatment is ongoing, this visit is not an initial evaluation.

Sample Documentation As noted in Chapter 14, documenting treatment in mental/behavioral health can seem intimidating to someone who

is used to working with clients who present with physical dysfunction. For this reason, we will backtrack a little and break down the components of the note.

First, notice that this note is basically about meaningful occupation. Tom is not able to complete his ADL and IADL successfully because of the exacerbation of his illness. For example, he is not bathing regularly. You might find this with a client whose rheumatoid arthritis has exacerbated so that she is unable to turn the knobs on the shower, or with a client whose tetraplegia interferes with his ability to transfer into the shower. The intervention with Tom is different, but the problem of not showering due to some interference (in Tom’s case, preoccupation with internal dialogue) is an ADL issue.

Problems and Goals:

In preparation for writing problems and goals, students could start by making a list of the problems Anne sees today in her visit with Tom. These might include the following:

◆ Poor diet (not eating well) ◆ Poor hygiene ◆ Noncompliant with medication regimen (taking meds “sometimes”) ◆ Not sleeping ◆ Sedentary (sits all day) ◆ Thinks neighbors are talking about him ◆ Weight gain ◆ Hard time remembering things ◆ Does not tolerate large groups of people ◆ Hears voices ◆ Rocking ◆ Watching static on TV



◆ One-word delayed responses ◆ Dressed inappropriately ◆ Messy environment

From the list of problems they identify in the video, students might be asked to word problem statements correctly and identify those which are a priority. For example, Anne is particularly concerned about Tom’s medication noncompliance, which she feels is the basis for many of his other ADL, IADL, social, and sleep problems. She writes:

Problem #1: Client does not remember to take his medications, resulting in increased symptomology, which interferes with ability to perform ADL and IADL tasks successfully.

She is also concerned about his nutritional intake, his personal hygiene, and his reluctance to leave the house. In this situation, she does not speak of assist levels since Tom does these tasks alone in his own home. She does plan to increase his assist levels, however, by increasing her contact with him to provide verbal cueing. At this point, it is not clear how much verbal assist he will need to be successful.

Next, students might be asked to write goals for each of the problems to be addressed. For example: ◆ Client will shower with verbal cues by telephone at least 6/7 days next week. ◆ Within 1 week, client will be compliant with medication regimen at least 4/7 days as evidenced by pills remaining

unused in mediset. ◆ Client will report eating at least 3 items other than pizza within 1 week after going to the food pantry.

Remember that the treatment plan is always a work in progress. The goals today may turn out to be unrealistic for Tom, in which case they will change. For now, just for practice, students might try writing some correctly worded COAST goals for Tom based on the problem statements they have written.

SubjectiveNote that this occupational therapist doesn’t have much to work with in terms of direct quotes for her “S.” In

Chapter 7, you learned that one of the characteristics of a good treatment session is using your time with the client to communicate effectively—to elicit specific information regarding the client’s patterns of daily living; functional status; and perception of his problems, needs, motivation, priorities, and goals. Anne is able to use Tom’s brief one-word answers to follow up with questions that tell her quite a bit about how he sees his situation and what he is willing to do. Although she will use some direct quotes, she will often need to say, “questioning revealed…” or “when asked…” to combine his one-word answers into a coherent “S.”

ObjectiveIn this situation, with a client who has not bathed or washed his hair recently, whose house is stacked with dirty

pizza boxes, and who is rocking and watching static on TV, it might be tempting to be judgmental in your observation. Notice that Anne describes his situation and his behavior using as little mental health jargon as possible. For example, she describes the way he is dressed rather that stating that it is “inappropriate.” She reports what he says rather than using words like “paranoid” or “delusional.” Those words can be used in the Assessment if she feels that they describe his thinking.

Having written problems and goals, students may be asked to write an “S” and an “O” from the video. There are many correct ways to do this. No two students (as well as no two therapists) would write the same subjective and objective data. It will depend entirely on what the therapist considers most important in what he or she sees. Here is an example:

S: Client’s verbalizations consisted mostly of one-word answers to questions and the phrase, “You know how it is.” Questioning revealed that the client is sometimes taking his medication, that sometimes he hears voices, that he is eating only pizza, which “has vitamins” and that he is preoccupied with the neighbors who are watching him and saying that he is fat. When asked what he does during the day, he replied, “Sit.”

O: Client participated in a 15-minute assessment of functional status in his home to ascertain current level of symptoms associated with schizophrenia and its impact on his ADL and IADL status, sleep, and social participation. Client presents with flat affect and little eye contact, wearing long-sleeved flannel shirt and down vest with shorts, a base-ball cap, and sunglasses. He is rocking and watching static on TV. His hair is unwashed and he smells of not having showered recently. With encouragement, he agreed to shower tomorrow morning if cued with a phone call, to go to the food pantry, to see his doctor if accompanied by agency staff, and to use a medication organizer to remember to take his medications as prescribed. Verbal cues given to fill the medication organizer correctly today.



If Anne had wanted to use categories for her “O,” she might have chosen the following: ◆ ADL to discuss bathing, sleeping, eating, and dress ◆ IADL to discuss housekeeping and the appearance of his apartment ◆ Social participation to discuss his not leaving his apartment, his concern about the neighbors, and his dislike of

large groups of people ◆ Medication compliance to discuss how often he reports taking his medication, and introduction of the medication

organizerUsing the “S” and “O” students wrote from the video (or the ones provided here), the students could be asked to write

an assessment and plan for Tom.

Worksheet for Tom Allen

S: Client’s verbalizations consisted mostly of one-word answers to questions and the phrase, “You know how it is.” Questioning revealed that the client is sometimes taking his medication, that sometimes he hears voices, that he is eating only pizza, which “has vitamins” and that he is preoccupied with the neighbors who are watching him and saying that he is fat. When asked what he does during the day, he replied, “Sit.”


AssessmentWrite your “A” in the box below: Remember to identify problems, progress, and rehab potential. Look back at

Chapter 9 to review client factors, performance skills, performance patterns, and context. How do these relate to Tom?

For problems, begin your sentence with the contributing factor and identify its impact on his ability to engage in occu-pation. Does his willingness to try the medication organizer and his ability to use it with verbal cues represent progress or rehab potential? What about his agreement to shower with verbal cues and his willingness to go to the food pantry and to visit his doctor if accompanied?

Remember to end your “A” with “Client would benefit from…” and justify continued occupational therapy services. Re-hospitalization is a very expensive proposition. Keeping Tom out of the hospital and in his own home with agency support is much more cost effective. Since the “A” is Anne’s assessment of the meaning of Tom’s verbalization and behav-ior, Anne may use more psychiatric terminology.



Plan Notice that Anne has discussed her plan for Tom with him and has gained his agreement to try some of the things

she has in mind. While he is not in wholehearted agreement with eating something besides pizza and leaving his home for social participation, she has established a starting place and has made certain that Tom feels that he has the support he needs to try out some of her ideas. Write your plan for Tom in the box below. Remember to start with the frequency and duration of the care you plan to provide and what you plan to do to address Tom’s needs.

Here is a completed SOAP note for Tom:

S: Client’s verbalizations consisted mostly of one-word answers to questions and the phrase, “You know how it is.” Questioning revealed that the client is sometimes taking his medication, that sometimes he hears voices, that he is eating only pizza, which “has vitamins” and that he is preoccupied with the neighbors who are watching him and saying that he is fat. When asked what he does during the day, he replied “Sit.”


A: Client’s noncompliance with medication regimen has resulted in increased symptomatology, including poor hygiene, paranoid ideation, decreased activity level, poor nutrition, and minimal communication with flat affect and little eye contact. His willingness to use the medication organizer, shower if cued by telephone, and go to the food pantry and his doctor accompanied by agency personnel show good potential to meet his stated treatment goals. Client would ben-efit from increased contact to cue patient to take medications as prescribed and to re-evaluate ADL status frequently.

P: Continue to contact client in person 3 more times this week with daily telephone calls to increase independence in medication compliance and in basic and instrumental ADLs. Client to be taken to the food pantry tomorrow to select foods for a more balanced diet. Medication compliance with medication organizer to be determined each visit this week. Appointment with psychiatrist to be scheduled. Recommend immediate change to a Level III status to prevent further decompensation and possible need for hospitalization.

tom’s Progress

HistoryThree weeks ago, when Anne visited Tom, she found Tom’s health status deteriorating. He was not complying with

his medication regimen and not attending to his basic ADLs. She recommended placing him on a Level III status under which he would be seen 3 to 5 times weekly. This allowed her to see him 4 times the first week and 3 times last week and this week. On the days he is not seen, he receives a phone call either by Anne or (if it is her day off) by the staff person who is on call. She has watched him fill his medication organizer weekly and has made a note of how many missed doses of medication remained in the organizer at the end of each week. She took him to see his psychiatrist during the first week of his Level III status, and has scheduled a follow-up appointment for tomorrow. After today’s visit and the psychiatrist appointment, she will make a recommendation regarding whether he needs to remain on this high level of care or move back down to Level II, under which he would be seen once to twice weekly, along with phone calls and transportation as needed.



Contact notes are required for each visit made by a caseworker at River Region Community Support Center. For a change in level of care, however, more comprehensive notes are required. Because Anne is recommending a change from Level III to Level II today, she will write a progress note summing up the progress she sees in Tom since his level change 3 weeks ago. The progress note will include a summary of the services provided, the client’s current performance and an updated plan based on changes seen to date.

Sample Documentation You might begin by asking the students to brainstorm the progress they see in Tom in this video. This might include

such things as the following: ◆ Showering twice weekly ◆ Missed medication only twice last week ◆ Eating some foods other than pizza ◆ Went to the PSR last week ◆ Neighbors are less of a concern ◆ Sleeping better ◆ Leaving the house twice weekly ◆ Less clutter and no empty pizza boxes ◆ Watching TV show (the Weather Channel) rather than static on TV ◆ Hair cut and washed; grooming improved ◆ Less delay before answering questions

Then, divide the progress between the things Tom reports and the things that are observed. This will help set up subjective and objective portions of the note.

Next, you might have the students brainstorm remaining problems. These would include such things as the following: ◆ Still doesn’t initiate conversation ◆ Not much social participation ◆ Not taking 100% of medication ◆ Continued repetitive motions and rocking ◆ Needs assistance to go to doctor or grocery store ◆ Still concerned about the neighbors ◆ Still needs telephone cues to shower and to remember medications ◆ Continues to have decreased activity levels

This preparation will make writing the progress note easier. The subjective statement provides the client’s report of what has occurred during the period covered by the note.

There is now a list of these items, which have been separated from the observations. This now needs to become a coher-ent whole.

The objective section includes the summary of services provided as well as the client’s current status. The “O” begins as always with when, where, and for what purpose the client participated in this particular visit. The summary of ser-vices is not included in a contact note, so this is a “new learning” item for students. This progress note covers a period of 3 weeks. Anne wonders if Tom will be able to maintain his increased functional levels if he returns to Level II care, which is less labor intensive and less expensive to provide. Tom’s psychiatrist will have input on this decision when he sees Tom tomorrow.

As always, the assessment section reports on continuing problems, progress toward goals, and rehab potential, while the plan updates the occupational therapist’s plan for continuing services. Brainstorming can be used for these as desired. When students are engaged in new learning, it can be very helpful to hear other ideas than their own. It allows them to have help from other students without cheating.

Here is a Progress Note for Tom:

S: Client reports that he is feeling “a little better.” He is bathing twice a week, has only missed “a couple of doses” of medication, and is trying different foods. He reports that he went to one PSR group, but was bothered by the number of people present there. When asked if he would attend future PSR groups, he replied, “maybe bowling.” He reports adverse side effects of medication including sleepiness after the AM dose and drooling. Client reports that he has been sleeping better and also reports an increase in leisure activities, including watching TV, listening to music, and talking to friends on the phone. When asked about his concerns about the neighbors, he said, “Better now. You know how that goes.”



O: Client participated in a reassessment of his functional status in his home to evaluate progress in ADL status, sleep, and social participation for a potential reduction in necessary level of care. Level of Care:Client has been visited in his home 4 times weekly the first week he was on Level III care and 3 times each of the past 2 weeks. Client has been taken to see his psychiatrist for medication re-assessment and to the food pantry to increase foods included in his diet. Client has filled his medication organizer weekly with stand by assist for accuracy, and missed doses have been recorded and reported to the psychiatrist.Current Functional Status: Client is able to make short sentences and occasionally makes direct eye contact. Television is tuned to the weather station rather than static. Hair has been cut and client is groomed. Although still wearing down vest with shorts, clothing is more seasonally appropriate. Recovery issues discussed, including medication compliance to make him less frightened and more comfortable and side effects of medication that might cause him to discontinue taking it. He was encouraged to discuss the AM fatigue and drooling with his psychiatrist at tomorrow’s visit. He was encouraged to leave his apartment on a daily basis and to attend one of the PSR groups at least once per week. Client was observed filling his medication organizer and was able to do so without error. Three doses of medication were found unused in the medication organizer: one lunch dose and two evening doses.

A: Progress is shown by increased compliance with medications, improved personal hygiene, improved sleep, increased dietary variety, increased physical and social activity, and decreased anxiety about what the neighbors are doing or saying. Remaining problems include continued missed doses of medication, expressed concerns about the side effects of the medications, continued (although lessened) concern about the neighbors, all of which indicate that his illness is not yet stabilized at a safe level and could exacerbate under stress. His hygiene, although improved, is still not a daily habit which he performs independently. His concern about large groups of people limits his social contacts and his ability to navigate the community independently to keep his appointments, do his shopping, and complete IADLs. Consumer would benefit from continuing visits twice weekly and daily telephone calls for 2 more weeks to prevent relapse. He would also benefit from stand by assist in filling his medication organizer weekly.

P: Tom will continue to receive visits in his home once to twice weekly as his condition warrants, with phone calls in between visits. He will be accompanied to the psychiatrist tomorrow in order to lessen his concern about being around other people, as well as to address his accuracy in reporting and to coordinate any medication changes that may occur. If the psychiatrist concurs, recommend decreasing Tom’s level of care back to Level II, with continued stand by assist to fill the medication organizer. Encouragement will be provided to continue to increase dietary variety and social interaction. Transportation will be provided to the food pantry and doctor as needed until Tom is comfortable riding the city bus again.

John

HistoryJohn is a 45-year-old married construction worker who was admitted to the hospital 2 days ago for the second time

in 10 days. Prior to his first admission, he was picked up in a park by the police, who found him walking on the top on the jungle gym at midnight. He was diagnosed with schizophrenia and given Haldol (haloperidol), which he quit taking as soon as he was discharged. At that time, his mania exacerbated and he felt like a “sure winner.” He went to the gam-bling boats, where his losses included not only the money he had with him, but also the truck he uses in his construction business and his wife’s car. His wife of 23 years was furious and said she had had enough and was leaving. John became very upset and threatened suicide. His wife called the police, who returned him to the hospital. He is diagnosed as bipo-lar disorder with OCD and borderline features, self-medicating with alcohol. He is being given Depakote (divalproex sodium) as a mood stabilizer, but is resistant to taking it.

John has been in the hospital 2 days this admission, and is seen daily in occupational therapy groups. He has been evaluated and is currently receiving some individual occupational therapy sessions as well as the group sessions. Expected length of stay is about 5 days.

Sample Documentation In Chapter 14, a different method of stating problems in mental health settings was discussed. John is hospitalized and

will have an interdisciplinary treatment plan. Have the students try writing goals for John in this format. In reality, these goals would be selected by the treatment team as a whole, and would not be the responsibility of the occupational thera-pist, although the occupational therapist would contribute to it. Problem statements might include some of the following:



Problem: Lack of insight into his illnessBehavioral Manifestation: John perceives external circumstances to be negatively controlling his life. He says he has been managing his own illness for a long time and his current hospitalization is the result of being given the wrong medication.

Problem: Potential for noncompliance with medication regimenBehavioral Manifestation: John says Depakote makes him fat, “brings [him] down,” is expensive, and will interfere with doing his job, but he will take it until discharge.

Problem: Lack of impulse controlBehavioral Manifestation: John lost his money, his construction truck, and his wife’s car gambling because he “knew” he would win.

Problem: Suicide riskBehavioral Manifestation: John threatened suicide if his wife left him.

Problem: Self medicates with alcoholBehavioral Manifestation: John reports drinking approximately a 6-pack daily in order to be able to go to sleep.

Problem: Disrupted sleep patternsBehavioral Manifestation: John reports sleeping 3 to 4 hours per night and waking up early.

Problem: Not accepting responsibility for his behavior/Not motivated to changeBehavioral Manifestation: John blames others (“cops,” doctor, wife) for his hospitalization and says the best way to help him is to get his wife and vehicles back for him.

Problem: Inability to focus on taskBehavioral Manifestation: John exhibits flight of ideas, needing redirection to stay on topic. He also exhibits push of speech, not stopping to consider what he wants to say before he says it.

Goals for John will be set by the interdisciplinary treatment team in this situation, and will not be the responsibility of the occupational therapist. The occupational therapist will, however, need to figure out how to meet these goals in the individual sessions and/or groups offered daily.

In the following SOAP note, we will pause after the “O” to consider what problems John revealed in this treatment session, what concerns these raise, and what rehab potential is present, since these will be assessed in the “A.”

David chose a symptom identification task for his individual session with John, since this task addressed several of John’s problems. Notice David’s therapeutic use of self with John. While not feeding into John’s denial, David is still warm and nonjudgmental, listening and providing feedback in a way that feels supportive to John, as though David is somehow on John’s side against this illness.

S: John talked about the events leading up to his hospitalization and his current symptoms. Main themes included being frustrated, people not leaving him alone, recent events not being his fault, and medication concerns. He denied having a plan for suicide, admitting that the suicide threat was an attempt to keep his wife from leaving, and stated that the best way to help him would be to get his car, truck, and wife back for him.

O: John participated in an individual ½-hour session for symptom identification. He talked rapidly with few pauses in his verbalizations and required frequent redirection to task. Using a chart of the body, John identified the following symptoms:

■ Inability to sleep well or long ■ Racing heart and mind ■ Jittery stomach ■ Feelings of frustration, sadness, and heartbreak ■ Need to be active ■ Feeling restricted by others

In a treatment session consisting mostly of talking, it is sometimes difficult for students to decide what to put in the “S” and what to put in the “O.” David elected to put a summary in the “S” and to use the task of making a body chart to organize the symptoms John listed. Notice that he described the client’s behavior, “client talked rapidly with few pauses” rather than saying “push of speech” or “flight of ideas,” although he may assess this behavior in these terms in the “A.”



Stop here and ask the students to identify the problems identified in the “S” and the “O,” as well as any potential for rehab they see in this session. Some of the following might be noted:

Problems: ◆ Noncompliance with medication ◆ Denial of responsibility for his actions ◆ Self-medication with alcohol ◆ Suicide threat ◆ Needs frequent redirection to stay on task

Rehab Potential: ◆ Able to identify symptoms ◆ Engagement in task ◆ In tune with body sensations ◆ Recognition that suicide attempt may not be the best

way to deal with wife leaving

A: Concerns about expense and side effects of present medication along with stated preference to self-medicate with alcohol raise concerns about relapse and alcohol dependence. Blaming others for his problems and not feeling any personal responsibility for the events leading up to his hospitalization show an external locus of control and limit his ability to problem solve more effective coping strategies. Engagement in task, willingness to attend and participate, and ability to identify symptoms all show good potential for learning to notice and manage future exacerbations of illness. Recognition that suicide threat might not have been the best way to handle his wife’s threat to leave him shows potential for considering alternate ways of handling problems, symptoms and feelings. John would benefit from activi-ties that increase insight and internal locus of control and development of coping strategies.

In this note, David chose not to address the inability to focus on task or the push of speech, which he considers to be indications that the current medication is not yet maximally effective. In a short length of stay, these do not concern him as much as the more basic problems of insight into illness and lack of adequate coping strategies. Another therapist might see this differently and might have more concern about his inability to slow down his thinking and activity.

P: John will continue to participate in group and individual sessions until discharge to increase insight into problems and refocus John onto individual responsibility and internal locus of control. Alternate coping strategies will be taught. Within 2 days, John will verbalize an ability to impact his own life circumstances.

In this situation, David chose to end his plan with a goal in order to make it a little less nebulous.

John’s Progress

HistorySince his admission on Sunday evening, John has been seen in occupational therapy twice daily for group treat-

ment sessions, including life skills group (daily), assertion group (Tuesday), leisure skills/exercise group (Monday and Wednesday), and task group (today, Thursday). He attends willingly and voluntarily contributes his ideas to the discus-sion. He missed the assertion group on Tuesday due to an appointment with his wife and the social worker. He has also been seen individually twice: once for symptom identification and again today for coping strategies. He is taking his medication as prescribed and is scheduled for discharge tomorrow. Prior to discharge, the occupational therapist plans to meet with John to go over his discharge plan and teach John some progressive relaxation exercises.

The goals set by the interdisciplinary treatment team on admission were as follows:1. Verbalize a willingness to take medications as prescribed after discharge2. Have a written plan for coping with symptoms of bipolar illness, including strategies for being able to sleep, work,

and relate effectively with his wife3. Verbalize a willingness to seek help when he notices exacerbation of symptoms.

Progress notes summarize the treatment interventions that have been used since the last note, and discuss changes in the patient as a result of treatment. Goals are reconsidered and noted as met or not. The specific criteria for a progress note can be found in Chapter 13 of your text.

Sample Documentation The following worksheet is provided to help the students organize their thoughts while watching the video:




John’s Progress—Worksheet

◆ When will John be discharged?

◆ What does David plan to do in the one session remaining?

◆ What goals does John have for himself?

◆ What coping strategies does John identify in this treatment session?

◆ Treatment interventions used were listed in John’s history for this video. What changes do you see in John as a result of treatment?

◆ What indicators of rehab potential do you see?

◆ What changes in goals do you see?

◆ What problems remain?

◆ Is there evidence of a home program, instruction for caregiver, or plan for the future?



Students might identify some or all of the following items listed as they watch John’s treatment session: ◆ When will John be discharged?

■ Tomorrow ◆ What does David plan for tomorrow’s occupational therapy sessions?

■ Teach relaxation techniques ■ Compile a written list of John’s preferred coping strategies

◆ What goals does John have for himself? ■ Sleep well ■ Stabilize/restore relationship with wife ■ Return to work

◆ What coping strategies does John identify in this treatment session? ■ Crisis line ■ Individual therapy ■ Relaxation techniques ■ Medication (cheap OTC such as Unisom [doxylamine] or Benadryl [diphenhydramine]) ■ Hobbies• Eating out• Reading Zane Grey western novels

◆ Treatment interventions used were listed in John’s history for this video. What changes do you see in John as a result of treatment?

■ Reports being “more calm” ■ Mood more stable ■ Sleeping better ■ Decreased push of speech ■ Decreased agitation ■ Able to attend to task/focus ■ Able to recognize onset of symptoms of mania ■ Recognizes need for hospitalization ■ Recognizes effectiveness of Depakote ■ Able to set goals ■ Able to identify coping strategies ■ Beginning to see that his actions were involved in his admission ■ Emerging internal locus of control

◆ What indicators of rehab potential do you see? ■ Attendance and participation in groups indicates good potential to acquire additional strategies for relapse

prevention. ◆ What problems remain?

■ Continued use of alcohol ■ Concern about the expense of prescription medication ■ Continued ambivalence over locus of control ■ Unfamiliarity with relaxation techniques

S: John reports feeling calmer, sleeping better, and recognizing that the medication is helping his mood even though he is still concerned about its expense. In a discussion of coping strategies John said, “I honestly believe I am moving in the right direction.” He reports an ability to recognize the early stages of exacerbation of his illness.

O: Since admission John has attended 4/4 life skills groups, 3/3 leisure skills groups, and 1/1 task group. He missed asser-tion group due to an appointment with his wife and the social worker. He attends groups without prompting and con-tributes his ideas. Today, John participated in an individual session focused on discharge planning and development of coping strategies. As of this date, he is able to attend to task without redirection; to set goals for himself in the areas of work, sleep, and relationships; and to identify past and potential coping strategies.



A: John’s willingness to attend and participate in groups and to recognize the benefits of his current hospitalization indi-cate progress toward developing insight into his illness and identifying meaningful goals and coping strategies that will improve his quality of life. Emerging ability to recognize early symptoms of bipolar disorder will allow John to use the coping strategies he has identified before his work and relationships are disrupted. Ability to acknowledge the part his own actions played in police intervention and subsequent hospitalization show an emerging internal locus of control which will assist him in relapse prevention and achievement of his work and relationship goals. Remaining problems include lack of familiarity of relaxation techniques and ambivalence toward using prescribed medication in place of alcohol to stabilize mood and improve sleep. John would benefit from instruction in progressive relaxation techniques and from formalizing his emerging plan for identifying early symptoms and making changes before rehospitalization becomes necessary.

P: Provide one more treatment session for education in progressive relaxation techniques, for increasing skills in relapse prevention, and for formalizing a specific (written) plan for the coping strategies he plans to use following discharge. Goals #1 and #2 continued as written. Goal #3 met this date.

conclusIonWe hope that you and your students find this textbook and Instructor’s Manual useful. We invite your comments,

criticisms, ideas, and suggestions for ways to improve this book. We also invite you to submit examples of documenta-tion that you consider to be good examples for a particular practice setting. When submitting a note, please include your name, address, phone number, and e-mail so that the authors may contact you regarding permission to publish the note in future editions of this textbook. Please send your comments, suggestions, or notes to:

Crystal Gateley, PhD, OTR/Lc/o SLACK IncorporatedProfessional Book Division6900 Grove RoadThorofare, NJ 08086

reFerencesAmerican Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain & process (3rd ed.).

Bethesda, MD: AOTA Press.Borelli, L. (2014). Why using pen and paper, not laptops, boosts memory: Writing notes helps recall concepts, ability to understand.

Medical Daily. Retrieved from http://www.medicaldaily.comCahill, S. M., & Bowyer, P. (2015). Cases in pediatric occupational therapy: Assessment and intervention. Thorofare, NJ: SLACK

Incorporated.Lowenstein, N., & Halloran, P. (2015). Case studies through the health care continuum: A workbook for the occupational therapy stu-

dent (2nd ed.). Thorofare, NJ: SLACK Incorporated.