AI Scribe for Occupational Therapists

INITIAL OCCUPATIONAL THERAPY EVALUATION

Patient: 67-year-old male, R-handed, retired electrician
Date of Eval: Today (POD #14 from acute hospitalization)
Setting: Inpatient rehabilitation
Dx: L MCA ischemic CVA, R-sided hemiparesis (G81.91), expressive aphasia (R47.01)
PMH: HTN, T2DM, hyperlipidemia, prior TIA 2019.
Meds: Aspirin 81mg, atorvastatin 40mg, metoprolol 25mg BID, metformin 500mg BID, lisinopril 10mg.
Prior level of function: Independent in all ADLs/IADLs, drove, lived with spouse in 2-story home (bedroom upstairs).

SUBJECTIVE:
Pt reports frustration with R UE weakness and difficulty completing self-care. Spouse present, reports pt has been "trying hard" but needs cueing for sequencing. Pt's goal: "I want to dress myself and get back home." Spouse's goal: safe transfers and toileting before discharge.

OBJECTIVE:
Vitals: BP 138/82, HR 78 reg, SpO2 98% RA. No acute distress.
Mental status: A&Ox3, mild expressive aphasia, follows 1-step commands consistently and 2-step commands with cues.
Cognition (MoCA): 22/30 — losses in delayed recall (2/5), serial 7s (2/3), and clock draw (2/3); attention and orientation intact.

ROM (R / L UE, AROM):
- Shoulder flexion: 90° / 170°  • Abduction: 80° / 165°
- Elbow flexion: 110° / 145°  • Wrist ext: 20° / 65°
- Finger flexion: gross composite to mid-palm / WNL

MMT (R UE):
- Shoulder flexors: 2+/5  • Abductors: 2/5
- Elbow flexors: 3-/5  • Wrist extensors: 2+/5  • Grip (Jamar, R): 8 lbs vs L 62 lbs

Sensation (R UE): Light touch impaired distal to elbow; proprioception impaired at wrist and fingers; stereognosis impaired.
Tone: Modified Ashworth 1+ at elbow flexors, 1 at wrist flexors. No subluxation noted; shoulder is supported in sling.
Coordination: R UE — unable to perform finger-to-nose due to weakness.
Visual / perceptual: No L neglect. Tracks midline. Figure-ground intact.

Modified Barthel Index (today): 42/100 — deficits driven by self-care, transfers, and toileting.
- Feeding: 5/10 (modified setup, uses L hand, built-up utensils helpful)
- Bathing: 0/5 (max A x1)
- Grooming: 0/5 (max A)
- Dressing: 2/10 (UB with mod A, LB max A)
- Toileting: 2/10 (mod A x1, requires grab bars)
- Transfers (bed/chair): 8/15 (mod A x1)
- Mobility: 5/15 (uses RW with CGA)

IADL: Unable to assess most domains in current setting; spouse reports pt previously managed finances, meds, cooking — none safe at this time.

ASSESSMENT:
67 y/o R-handed male, POD #14 from L MCA CVA, demonstrates moderate R UE hemiparesis, mild cognitive deficits (memory/executive function), and significant ADL dependence. Strengths: motivated, supportive spouse, no neglect, intact safety awareness with cueing. Excellent rehab candidate. Discharge home with spouse anticipated if pt achieves Mod I in toileting, transfers, and UB dressing within 3–4 weeks.

GOALS:
STG (4 weeks):
1. Pt will complete UB dressing with min A using one-handed adaptive techniques.
2. Pt will perform sit-to-stand transfer with CGA and RW for toileting.
3. Pt will demonstrate AROM R shoulder flexion to 120° to support functional reach.

LTG (12 weeks):
1. Pt will be Mod I in self-feeding, grooming, and UB dressing using adaptive equipment.
2. Pt will be Mod I with toileting using grab bars at home.
3. Pt will return home with spouse, safe with first-floor setup and home program.

EQUIPMENT RECOMMENDATIONS:
Built-up handle utensils, rocker knife, dressing stick, long-handle sock aid, reacher, tub bench, raised toilet seat with grab bars, and L-handed dycem placement. Will work with case management on home eval.

PLAN:
Frequency: 4x/week × 4 weeks then re-evaluate.
Interventions: ADL retraining (97535), neuromuscular re-education (97112) for R UE, therapeutic activities (97530), self-care/home management training. Co-treat with PT 2x/week. Family training planned with spouse weekly. Compensatory strategies introduced for memory (written checklists). Plan of Care to be co-signed by physiatrist.

OTR signature: M. Nguyen, OTR/L — Lic #54321