De La Salle Health Sciences Institute

College of Rehabilitation Sciences

Occupational Therapy Department

Initial OT Notes
November 29, 2016
Name/ Initials of patient: B. C.
Age, gender: 24, Male
Diagnosis: Bipolar 1 Disorder
OT Schedule: 1pm to 5 pm
Gen. behavior of patient during evaluation session:
The client was cooperative during the screening and assessment part. The
client was able to answer to every question the therapist was giving, but was
observed to make fleeting eye contact with the therapist. The client made a
5 second eye contact with the therapist at the very first parts of the
questions and when probed why he chose such answer, he would then look
away while explaining.
Chief complaint:
- According to the patient: Triggering episode nabagansya.
- According to the caregiver (mother): Iba na kilos nya, nagsisigaw, nagaglit
sa kapatid, hindi mapakali sa bahay.
Goals:
- According to the patient: Makabalik sa pag-aaral.
- According to the caregiver (mother): Maging compliant sa medications.
Sana maregulate na yung tulog nya ng by 9pm or 10pm.
Pertinent Subjective Information:
-

The patients first admission was on 2009. He was admitted once at

Divine Mercy Medical Center in Mandaluyong City, but the rest of his
admissions to a psychiatric facility was in PGH. The clients prominent
habit before he was admitted for the 7th time was to watch television
series such as NCIS. He spent so much time watching that it was
already affecting his sleeping patterns. According to his mother, the
patients excessive use of computer, such as cell phone, for gaming
also affected his sleep.
His caregiver reported that the reason for the patients noncompliance
in taking medications was that the patient mostly went home late, not
following the schedule of taking medication.
Objectives

To develop or improve
work skills and work
habits (related to

Activities
Assessment tools used:
Occupational Therapy
Task Observation

Performance
OTTOS was not given to
the patient since the
patient was already an
out-patient when the

De La Salle Health Sciences Institute

College of Rehabilitation Sciences
Occupational Therapy Department

education).

To develop or explore
interest, hobbies,

and assets.
To provide venue/s
for constructive use
of leisure time.

Scale (OTTOS)

Interest Checklist
Evaluation of Social
Interaction

Lawton IADL
Pittsburg Scale
Quality Index
(PSQI)

therapist was about to

conduct the assessment
on Thursday, December
1, 2016.
The
patient
was
observed
to
have
fleeting eye contact
with
the
therapist
during
the
interest
checklist
assessment.
He only made an eye
contact whenever the
therapist
stated
the
activities listed under
interest checklist then
immediately
looked
away after.
Lawton
IADL
assessment tool was
not given because the
patient
was
already
considered
an
outpatient
when
the
therapist was about to
conduct the assessment
on Thursday, December
1, 2016.

Assessment:
Interest checklist:
Based from the results, the patient is mostly interested in: Poker,
television, painting, camping, politics, scouting, religion, and conversation.
The least of his interest are: Bridge, popular music, holidays, and dating.
Evaluation of Social Interaction
The patient was observed to have an appropriate quality of social
interaction to his social partner.
Pittsburg Scale Quality Index
During the past months, the patient usually gone to bed at 4 am and got
up at 1 pm. The patient as experienced troubles sleeping within 30 minutes
and took medicine to help him sleep for three or more times a week.
During the past months as well, the patient rated the quality of his sleep as
fairly good.

Has poor self-control of the time he spends on watching television

De La Salle Health Sciences Institute

College of Rehabilitation Sciences
Occupational Therapy Department

and playing computer games

Has poor performance in health management and maintenance.
Intact sensory, neuromuscular and movement-related functions,
muscle and movement functions, and skin and related structure
functions.
Has good performance in ADLs such as feeding and functional
mobility as they are the only ADLs observed by the therapist as of
now.

Plan for next session:

To start with an OT management focusing treatment implementation
focusing on leisure exploration and participation. The managements
purpose is to decrease the clients usage of phone and to explore leisure
activities that are of his interest, such as reading, listening to music, and
watching movies.
Prepared by:

Noted by:

_________________________
Monique Joy S. Antaran
Hernandez, OTRP.

_____________________________
Ms. Pamela