Students learn practical application and active learning in lecture content. Designated as a service learning class.
Stacy Forden
Adult onsite and telehealth
Reflection
This semester adult onsite and telehealth clinic experience was beneficial to my learning because I was able to see more what it might look like if I was to be in an adult setting after I graduate. Clinic connected to my learning because what I was able to learn about in the program, I connected to my experience in leading clinic. I learned about energy conservation, Range and motion, and Adaptive devices all of which I was able to utilize in the clinic environment. Slcc has a pro bono clinic where individuals can come in and receive services that they need. I was able to see a few patients that delt with things like CVA’s, and Aspasia. I really enjoyed my experience in clinic this semester and could see myself working in this population.
Clinic
SLCC Pro Bono OT Clinic
Client Number and Initials
Session Date
3/28/24
Student Clinician
Stacy Forden OTAS
Supervising Therapist
Kristen OTA
Safety Issues/Precautions
Occupations Addressed (OTPF 4th - Table 2)
Activities of Daily Living (ADLs) —Activities oriented toward taking care of one’s own body and completed on a routine basis
Instrumental Activities of Daily Living (IADLs) —Activities to support daily life within the home and community.
Health Management —Activities related to developing, managing, and maintaining health and wellness routines, including self-management, with the goal of improving or maintaining health to support participation in other occupations.
Rest and Sleep —Activities related to obtaining restorative rest and sleep to support healthy, active engagement in other occupations.
Education —Activities needed for learning and participating in the educational environment.
Work —Labor or exertion related to the development, production, delivery, or management of objects or services; benefits may be financial or nonfinancial.
Play —Activities that are intrinsically motivated, internally controlled, and freely chosen and that may include suspension of reality.
X
Leisure—Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep
Social Participation—Activities that involve social interaction with others, including family, friends, peers, and community members, and that support social interdependence
SOAP NOTE
Subjective
Client stated, “ No migraine today” , “ My pecs are really tight” when student was stretching him and : Oh ya it is frozen” when mobilizing his scapula, &“ It was good today”
Objective
Client participated in 45 min session in SLCC pro bono clinic. Client Participated in preparatory stretching of his Deltoid, Pectoralis major & minor and levator scapula through flexion, internal, and external rotation of L UE. Pin and stretch technique of medial border of scapula as well as the pectorals was also applied. Client participated in Thai massage on his L LE, R LE, & L UE which included hip flexion, internal rotation, and Psoas mobilization as a continued preparatory activity to increase ROM for perverted activity of golfing. Client was educated on the use of a PT daisy chain as a medium to stretch his L & R UE while on the golf course to use in-between swings to decrease spasticity throughout play. Client practiced s/u or stretch with use of R UE X4 with X2 accuracy. Activity was graded down by making the loop bigger and dropping it down.
Assessment
Client values preparatory activity of stretching and has a extensive knowledge of anatomy d/t background. Client likes to be pushed passed his comfort limit and enjoyed the preparatory activity of Thai massage in evidence of subjective. Client found the AS of stretching with a daisy chain to be helpful and was able to s/u with Min A with the bigger loop. Client would benefit from cont. OT for AS as well as Increased ROM to participate in his preferred leisure activities.
Plan
Cont. OT P.O.C. for 1x/wk for 3 weeks c skilled interventions focusing on balance, and increasing ROM.
CPT Codes
Code
Justification
97535 – ADL/Self-Care Retraining
n/a
97530 – Therapeutic Activity
15 minutes of shoulder flex., finger grasp, and cross midline task
97110 – Therapeutic Exercise
10 minutes of shoulder flex. and elbow ext. reps task
97112 – Neuromuscular reeducation
10 minutes of shoulder abd and FM control of LUE
97140 – Manual Therapy
13 minutes of stretching of LUE to L fingers throughout tx session