Occupational Therapy Evaluation Report

Elizabeth Clinch
Utica College

OCCUPATIONAL THERAPY EVALUATION REPORT

BACKGROUND INFORMATION
Date of report: 3/1/16

Clients name: T.C.

Date of birth: 12/15/64

Date of referral: 11/6/15

Gender: Female

Primary intervention diagnosis/concern: Systematic lupus erythematosus (SLE)

Secondary diagnosis/concern: Fibromyalgia & myopathy
Reason for referral to OT: Managing symptoms (fatigue, generalized muscle weakness, physical
discomfort) and the impact of Lupus on daily life, as well as advocating for herself in her workplace.
Therapist: Elizabeth A. Clinch, OTS
Assessments performed:
1. Modified Fatigue Impact Scale (MFIS): Assesses patients level of physical, cognitive, and
psychological functioning in relation to fatigue. Patient reported during initial interview that she
had been experiencing an increase in lupus symptoms such as fatigue. She stated it was and still
is interfering with her functional daily activities such as her work duties, hobbies, grocery
shopping/outings and family activities. Completing the MFIS will show specific perceived
deficits in the physical, cognitive and psychological subscales of the assessment (National
Multiple Sclerosis Society, n.d.).
2. Snellen Chart: During initial interview patient reported a decrease in her visual acuity during
functional activities such as reading, driving, performing job duties; due to both lupus
medications and symptoms. Assessment chosen to establish a baseline in order to track during
therapy to show any changes in her visual acuity. Standing 20 feet away the patient reads the
smallest line they can see. For example, if the patient scores a 20/40 this means that a person with
typical 20/20 vision, can read the same line at 40 feet away (National Institutes of Health, 2016).
FINDINGS
Occupational Analysis:
Performance skills: During the fatigue assessment TC was able to independently answer all
questions on the self reported MFIS assessment scoring a 48/84. Specifically, the physical
subscale score was 27/36, cognitive subscale was 17/40, and psychosocial subscale was 4/8.
Observed performance prior to and during administering the MFIS was consistent with the self
reported assessment results. TC used a modified pen that was larger in diameter to allow for a
more comfortable grip while writing. During the 5 minute assessment it was noted that TC was
unable to grip the modified pen for the extent of the test, setting it down twice.
Motor skills:
1. Generalized muscle weakness (specifically in hands)
2. Physical activity

3. Physically uncomfortable
4. Uncoordinated movements
5. Social activities/participation due to fatigue
6. Motivation
7. Endurance
Process skills:
1. Executive functions (alertness and attention)
2. Disrupted thinking patterns
Social skills: Intact

Functional modifier: CK at least 40% but less than 60% impaired, limited or
restricted. Results specifically suggest 57% impaired.
G-code: G8990 Other PT/OT primary current status.

Client factors: TCs score for both R&L visual acuity on the Snellen Chart was 20/30 while
wearing prescribed glasses. TC also tested without glasses and scored for both R&L 20/70.
Continuance of lupus medications is impacting her visual function as reported by TC in
previously.

Visual function
1. Visual acuity

Modifier and G-code are based on the 20/30 test result:

-Functional modifier: CL at least 60% but less than 80% impaired, limited or restricted.
-G-code: G8990 Other PT/OT primary current status.

INTERPRETATION
Prioritization of need areas:
1.
2.
3.
4.

Fatigue impacting leisure, work and social participation

General weakness causing pain, discomfort and
Medications and symptoms of lupus affecting her visual function
Decreased motivation and endurance during daily activities due to fatigue

INTERVENTION PLAN
Mutually Agreed-On Long
Term Goals

Mutually Agreed-On Short

Term Goals

(in 8 weeks)

(in 2 weeks)

TC will increase participation

in desired occupations such as
quilting, shopping, family
activities, by increasing

TC will decrease general

muscle weakness as reported
on the MFIS, to functional
modifier CJ, through aquatic

Intervention
Approaches and Methods
Approach: Restore
Method: Aquatic therapy
exercise, relaxation &

general muscle strength and

decreasing discomfort and
pain reported on the MFIS,
within 8 weeks.

stretching and light exercise.

diaphragmatic breathing

TC will implement the energy

conservation schedule into her
lifestyle in order to decrease
fatigue, increase physical
activity and social
participation.

TC will report an increase in

motivation/participation in
desired occupations due to her
decrease in fatigue, reported
on the MFIS, functional
modifier goal of CJ.

Approach: Establish

TC will utilize suggestions for

home modifications and tips to
promote visual function and
increase home
management/care,
participation in job duties and
leisure activities.

TC will self report that she

began a desired hobby (e.g.
quilting, couponing)
successfully.

Approach: Modify

Method: Collaborate with TC

making a list of important
daily activities; establish a
daily schedule that supports
her lifestyle to promote energy
conservation, also by using
joint protection techniques.

Method: Adapt and try

commonly used objects such
as bold writing utensils; install
halogen/fluorescent lighting to
increase lighting, decrease
clutter in home/work space so
objects are easier to locate
(this will also improve
energy).

Expected frequency, duration and intensity: 3x/week for 8 weeks; 50 minute sessions
Location of intervention: OT OP rehabilitation clinic/possible home evaluation to implement
adaptations/modifications to home environment.
Anticipated D/C environment: Home environment, work, community

Elizabeth A. Clinch, OTS

Signature:
April 13th, 2016

Date:

INTERVENTION SESSION PLAN

TIME
1:00

SPECIFIC METHOD
Discuss current schedule of daily activities, when
fatigue sets in and any coping strategies currently used.

1:10

Rank daily activities from greatest to least important.

Rationale
Recognizing daily activities to be
able to organize in order to be
successful in preventing fatigue
from occurring.
This will allow TC to complete
the most important activities first
in order to participate in her

1:20

Discuss implementing energy conservation techniques

into her daily routine (Important activities in the
morning, take rest breaks in between activities, try not
to over schedule).

1:30

Meet at the therapy pool to begin stretching;

demonstrate stretches utilizing a side bar for support
while stretching upper and lower extremities and the
back. Have TC join in after demonstrating stretches for
her. Rest for 1 minute of longer.
Light upper extremity exercises using a water fan
paddle. Rest for 1 minute or longer/can sit on pool
bench if needed.

1:40

1:50

Light lower extremity exercises using a pool noodle

under ankles and then knees; flex x15 both sides. Rest
for 1 minute or longer/utilize pool bench if needed.

desired occupations.
Ideally so she can perform all of
her desired activities that are
important to her daily.

Aquatics to decrease muscle

weakness, physical discomfort
and pain. Increases ROM.

Decrease any muscle tension,

promotes cardiovascular
circulation, and promotes deep
breathing.
Decrease any muscle tension,
promotes cardiovascular
circulation, and promotes deep
breathing.

References
National Multiple Sclerosis Society. (n.d.). Modified Fatigue Impact Scale (MFIS). Retrieved from
http://www.nationalmssociety.org/For-Professionals/Researchers/Resources-forResearchers/Clinical-Study-Measures/Modified-Fatigue-Impact-Scale-%28MFIS%29
National Institutes of Health. (2016). Visual acuity test. Retrieved from https://www.nlm.nih.gov/
medlineplus/ency/article/003396.htm