Title: 
Headings:  Contraindications / Precautions for Treatment:
                  
Department
 
of
 
Rehabilitation
 
Services
 

Case
 
Type
 
/
 
Diagnosis:

Indications
 
for
 
Treatment:
 

Contraindications
 
/
 
Precautions
 
for
 
Treatment:
 

Evaluation
 

History
 
of
 
Present
 
Illness
 
and/or
 
Mechanism
 
of
 
Injury:
 
(obtain
 
via
 
chart
 
review)
 

Analysis
 
of
 
Occupational
 
Performance:
 

Motor
 
Skills:
   

Process,
 
Communication/Interactive
 
Skills:
  

Performance
 
in
 
Areas
 
of
 
Occupation:

Patient
 
Factors:
  

Assessment
 

Problem
 
List
 
:
 

Prognosis
 
and
 
Expected
 
Outcomes:
 

Goals

Treatment
 
Planning
 
/
 
Interventions
 

Frequency
 
&
 
Duration:
 

Patient
 
/
 
family
 
education
 

Recommendations
 
and
 
referrals
 
to
 
other
 
providers
 

Re-evaluation
 

Discharge
 
Planning
 

Original:
        
Revision:
Reviewers:
     

REFERENCES:
 


Content: All
 
rights
 
reserved
 
Analysis
 
of
 
Occupational
 
Performance: Motor
 
Skills: ROM
 
–
 
Assess
 
active
 
range
 
of
 
motion
 
(AROM)/
 
passive
 
ROM
 
measurements
 
of
 
bilateral
 
upper
 
extremities
 
(UE)
 


 
Strength
 
–
 
Assess
 
upper
 
bilateral
 
UE
 
strength
 


 
Coordination
 
–
 
Assess
 
manipulation
 
of
 
objects
 
during
 
functional
 
activity,
 
coordination
 
of
 
movements
 


 
Functional
 
Mobility
 
–
 
Assess
 
functional
 
transfers/mobility
 
in
 
patient’s
 
room,
 
(indicate
 
need
 
for
 
assistive
 
device). Progress
 
to
 
higher
 
level
 
of
 
function
 
as
 
appropriate
 


 
Vision
 
–
 
Assess
 
functional
 
acuity
 
(need
 
for
 
corrective
 
lenses)
 
and
 
general
 
fields
 
of
 
view
 


 
Activity
 
tolerance/endurance: Monitor
 
for
 
Shortness
 
of
 
Breath
 
(SOB)
 
with
 
exertion,
 
activity
 
intolerance,
 
and
 
need
 
for
 
supplemental
 
O24
 

Process,
 
Communication/Interactive
 
Skills: Cognition
 
–
 
Assess
 
level
 
of
 
arousal,
 
alertness,
 
orientation,
 
attention,
 
ability
 
to
 
follow
 
commands,
 
memory,
 
ability
 
to
 
learn
 
new
 
information,
 
problem
 
solving
 
and
 
insight
 
into
 
deficits,
 
as
 
well
 
as
 
best
 
mode
 
of
 
learning. Communication
 
–
 
Assess
 
the
 
patient’s
 
ability
 
to
 
express
 
and
 
understand
 
information
 

Performance
 
in
 
Areas
 
of
 
Occupation: Activities
 
of
 
Daily
 
Living
 
–
 
Assess
 
self-feeding,
 
grooming,
 
hygiene,
 
bathing,
 
dressing
 
and
 
toileting
 
skills. Note
 
the
 
need
 
for
 
adaptive
 
equipment
 
or
 
adaptive
 
strategies
 
to
 
complete
 
activity
 
and
 
how
 
patient’s
 
recent
 
surgery,
 
pain,
 
and
 
endurance
 
level
 
may
 
affect
 
performance. Note
 
participation
 
in
 
education,
 
regarding
 
family
 
members
 
who
 
are
 
present.