(N/A)
Use something significant the client says about his/her treatment or condition
The section needs to include: 1. Length of time, where, and for what the client was seen. 2. Report WHAT YOU SEE (chronologically or by categories) 3. Deemphasize the media. Leave yourself out, Focus on the client's response, do not be judgmental, specify when and how much assistance was needed, show skilled OT happening Response to patient or caregiver's education.
Go into each data of the objective section, asking yourself what problems, progress, and rehab problems do you see. So what?... Why is this important to the client. Anything that is less than WFL's should be addressed regarding impact on client's performance areas. Include education areas. End with: CLIENT WILL BENEFIT FROM SKILLED OT SERVICES IN ORDER TO ..... Goals may be included (according to some authors)
How often will the client be seen and for how long. What are you going to be working on, or if client will be discharged. Goals may be included (according to some authors)