NORTHLAND COMMUNITY AND TECHNICAL COLLEGE
OCCUPATIONAL THERAPY ASSISTANT PROGRAM
Fieldwork Case Study/Treatment Plan: 60 points
Occupational Profile
Create an Occupational Profile (Info below from the OT Practice
Framework 3rd Edition, pg. S13)
 Why is the person seeking service, what are their concerns
relative to engaging in occupations and in daily life
activities?
Bilateral knee replacement was the reason for the referral to
therapeutic services. Services are recommended as client has
decreased strength, endurance, standing balance, activity
tolerance and other complications. Concerns of engagement in
occupations include the inability to stand for more than 10
minutes during a functional activity and needs assistance with
most ADL’s and self-care activities.
 What occupations does the person feel successful with, and
what barriers are affecting the client’s success?
Prior to bilateral surgery, patient lived at home with others and
was independent in occupations. Barriers to occupations
include high risk for falls, decreased strength and endurance as
well as unassociated factors such as anxiety and depression.
 What aspects of the person’s environments or contexts
does the person see as supporting engagement in desired
occupations, and what aspects are inhibiting engagement?
Client was able to live at home with others, her muscle tone
was normal and had no cognitive impairments. Inhibiting
factors include physical limitations that result in the inability
to participate. Client also has a low pain tolerance which
makes participation in occupations post-bilateral knee
replacement.
 What is the person’s Occupational History (Life
Experiences)?
Client was a secretary for 30 years and loved her job. She was
married and had 4 children, none of which live around the
area. She has resided in Alexandria for the past 12 years.
For Total Points: 10 pts.
All information is included, detailed, organized, professional, no
errors/appropriate grammar; provides a clear picture of the patient, diagnosis,
and need for OT
1 pt. for each item:
 Why is the person seeking service, what are their concerns relative to
engaging in occupations and in daily life activities?
 What occupations does the person feel successful with, and what
barriers are affecting the client’s success?
 What aspects of the person’s environments or contexts does the person
see as supporting engagement in desired occupations, and what aspects
are inhibiting engagement?
 What is the person’s Occupational History (Life Experiences)?
 What are the person’s values and interests?
 What are the person’s daily life roles?
 What are the person’s patterns of engagement in occupations, and how
have they changed over time?
 What are the person’s priorities and desired targeted outcomes related
to occupational performance, prevention, participation, role
competence, health and wellness, quality of life, well-being, and
occupational justice?
- 1 pt. if any of these items are missing
o *Make sure basic info such as age, family, where they live, any
cultural beliefs, symptoms of diagnosis, etc. are included in the
Occupational Profile.
- 2 pts. If paper has no errors/appropriate grammar, is detailed/organized,
and flows well.
  What are the person’s values and interests?
Client values being able to go out for coffee, being social, her
appearance but does not have any specific hobbies. When
asked what she enjoys doing she responded, “Oh whatever I
feel like that day.” Client values being going to a Lutheran
church when she is able.
 What are the person’s daily life roles?
Daily life roles include caring for herself and her household
that she lives in with others. She is responsible for all self-
cares.
 What are the person’s patterns of engagement in
occupations, and how have they changed over time?
Engagement now takes a longer period of time. The client was
active in her community and would like to be again. She was
independent prior to admission and is working to return to this
level.
 What are the person’s priorities and desired targeted
outcomes related to occupational performance, prevention,
participation, role competence, health and wellness, quality
of life, well-being, and occupational justice?
Client’s priorities are set on being independent in ADL’s,
moderate assistance in IADL’s. She desires to be back home as
soon as possible. She desires to get stronger and have the
ability to return home. Goals of OT include goals related to
Housekeeping, ADL’s, IADL’s and dressing which will
increase her quality of life as independence increases.

*Make sure basic info such as age, family, where they live, any
cultural beliefs, symptoms of diagnosis, etc. are included in the
Occupational Profile.

Treatment Plan (35 pts.)

Description of Diagnosis: State what it is and describe the diagnosis. Cite your sources. ____/4
Client has had bilateral knee replacement with secondary diagnosis of depression and anxiety. According to the National Institute of
Health, depression is defined as a mood disorder that affects the way an individual thinks, feels and handles daily activities. Further,
as stated by the National Institute of Health, Anxiety is defined by prolonged worry or fear that can get worse over time.
National Institute of Health. (2018). Depression. In NIMH . Retrieved March 12, 2018.
National Institute of Health. (2018). Anxiety Disorders. In NIMH . Retrieved March 12, 2018.

Pertinent information in treatment of Diagnosis: Identify anything that needs to be considered or taken into account with this
diagnosis. Any Precautions, concerns, etc. that need to be followed.
There are no precautions for this patient at time of treatment implementation.
Type of Setting: Short-Term Acute In-Patient
Freq./Duration of Therapy: 6x/week
Purpose: __/7
1. Purpose is Appropriate for goal (s). Write a brief description of why this treatment plan is needed, discuss the
client’s problems that make you feel this goal is necessary. (2 pts.)
Treatment plan is needed as client’s strength, endurance, and ability to perform functional tasks has been
hindered mainly due to post-surgery recovery. In order to increase the client’s strength, endurance, and
ability to perform functional tasks can be improved upon through Occupational Therapy intervention. Goals
of therapy focus on the clients level of independence during functional activities and engagement in
occupations.
2. Go through the OTPF and identify the Occupations, Client Factors, Performance Skills, and Performance
Patterns that are a weakness and are a reason for this treatment plan. Describe why the client has a deficit in
the different areas you choose. (4 pts.)
 Occupations:
ADL’s- Clients ability to stand and maneuver in order to perform independent ADL’s is hindered due
to bilateral knee replacement.
IADL’s- Client does not have sufficient endurance or level of functioning to successfully complete
IADL’s.
Leisure- As client has been staying in Acute care, she has had limited opportunities to engage in
leisure activities of her choosing post - knee surgery.
Sleep- Due to pain related to bilateral knee, client has a difficult time sleeping.
 Client Factors:
Emotional- Client is unable to control emotions as per secondary diagnosis.
Sleep- Sleep is affected due to pain.
Pain- Pain due to bilateral knee replac ement, low pain tolerance.
Muscle Power- Due to inability to move and age, muscle strength has been reduced.
Muscle Endurance- Client fatigues shortly after beginni ng activity that requires long periods of
standing.
 Performance Skills:
 Reaches- Client has decreased balance and is at a fall risk.
Stabilizes- Client needs to use ambulation devices, difficult to manage other objects simultaneously.
Moves- Initiating movement is extremely difficult, slow moving.
Flows-. Movements in UE and LE are rigid and are not smooth flowing.
Endures- Clients endurance is impaired due to physical inactivity.
Paces- Activity begins fast paced but as client fatigues, pace begins to slow
Navigates- Client bumps into objects in the therapy room and home consist ently
 Performance Patterns:
Routines- Due to bilateral knee replacement, client ’s routines take a longer time.
Habits- Because of acute care setting, regular habits have been lost until return home.
Roles- Ability to maintain role as caretaker or the house or self has been hindered since bilateral knee
3. Discuss the Context and Environment as it relates to this treatment and goal. (1 pt.)
 Context:
Personal- Has a low tolerance for pain and often breaks down in tears which inhibits effective therapy
until tears cease.
Temporal- Therapy is not at a consistent time during the day and pain varies making it more difficult
to judge improvement.
Cultural- At clients age, she is expected to be independent and not to need assistance with any
functional tasks.
 Environment:
Social- Client is unable to drive in order to attend social events which makes social participation more
difficult.
Total Points: All above must be present and appropriate, written professionally, minimal to no grammar/writing
errors.
Identify the top 3 problems and Create appropriate goals for OT Treatment (STG/LTG for each area). ___4.5
Develop a GOAL using SMART:
Simple/Specific , Measureable, Achievable/Action Orientated, Realistic/Relevant, Time Bound
Total Points: Goal(s) must meet the above requirements and be appropriate for individual, written professionally,
with minimal to no grammar/writing errors.
Problem #1: (.50 pt.) STG#1 (.50 pt.) Client will stand with standby assist for 5 minutes while
performing a functional activity across 3 sessions.
Client cannot stand for an extended period of time.
LTG#1(.50 pt.) Client will stand independently for 10 minutes while
performing a functional activity across one month of therapeutic intervention.
Problem #2 (.50 pt.) STG#2(.50 pt.) Client will successfully doff pants with moderate assistance and
AE such as a reacher, across 3 sessions.
Cannot perform LE Dressing
LTG#2(.50 pt.) Client will independently dress LE (pants, socks, shoes) with
moderate assistance within 2 months of therapeutic intervention.
Problem #3 (.50 pt.) STG#3(.50 pt.) Client will safely perform housekeeping task of washing/drying
dishes with moderate assist within 1 week of therapy.
Housekeeping tasks have become increasingly difficult.
LTG#3(.50 pt.) Client will safely perform all housekeeping tasks with moderate
assistance within 2 months of therapeutic intervention.
Treatment: __/17
1. Identify The Intervention Approach and the Primary Frame of Reference behind this treatment plan and your
rationale for choosing these. (2 pts)
Intervention approach: Establish and Restore- This Client previously was at a much higher level of
functioning. She has not deficits that are limiting her from returning to her previous level of functioning. She
is more than able to restore her functional capability to that of what it was prior to admission as well as
establish other techniques to make tasks easier or compensate for areas that do not fully recover.
Frame of Reference: Rehabilitation- Client will be able to restore to previous level of functioning to safely
return home post-bilateral knee. The client will use remediation techniques during rehab that will work
towards restoring her previous level of functioning through rehab exercises.
2. Total Treatment Session Time Listed, CPT Code Billed/Minutes/Units. (1 pt.)
97535- Self Care/Home Management Training- 40 Minutes / 3 Units
97530- Therapeutic Activity- 20 Minutes / 1 Unit
3. Describe each individual activity and the amount of time needed for each activity. Be sure you describe
exactly what will be taking place in the activity. (3 pt.) (minimum of 3 different activities)
Making Cheesy Scrambled Eggs & Toast/ Clean -up- 40 Minutes: Client will go through the entire process of
making a simple meal of cheesy eggs and toast per her request. She will set -up as if she was making it in her
home, cook, eat and then clean up after she is done eating.
Happiness Stones- 20 Minutes: Client will cut out pieces of construction paper to be glued onto colored
rocks. Different things to write will focus on secondary diagnoses of depression and anxiety. Client will
perform the activity while standing for as long as tolerated. T he client will identify things that make her
happy, things she enjoys, things she likes to do, or motivational quotes, sayings etc.
a. For each activity please list:
i. Relevance and Importance to the client (1 pt.)
Scrambled Eggs: Client has a main goal of returning home where she will need to safely
navigate the kitchen, cook meals and eat independently. Working on this activity will assess her
 readiness to return home and do these activities independently. Other go als include
Housekeeping tasks which will be addressed by washing the dishes.
Happiness Stones: Client has secondary diagnoses of anxiety and depression that should be
addressed for mental health well -being. The stepping stones will help her to realize th e things
she enjoys doing and also be motivating to read when she is having a hard day or needs a self -
esteem boost.
ii. Objects used and their properties (1 pt.)
Scrambled Eggs:
- Frying pan- hard, metal
- Spatula- rubber
- Food- decomposable
- Stove- heavy, metal, hot
- Soap- liquid
Happiness Stones:
- Stones- Hard, stone
- Marker- utensil
- Paper- paper, flimsy
- Scissors – sharp, hard
- Glue- sticky
iii. Space Demands (1 pt.)
Scrambled Eggs: Kitchen about 10x10 space, table for eating
Happiness Stones: table or surface to complete stones.
iv. Social Demands (1 pt.)
Scrambled Eggs: Assistance/interaction for cooking, when to turn the egg or pop the toast.
Possible assistance for washing task and putting away dishes
Happiness Stones: Assistance/interaction with fine motor tasks if it is too difficult.
v. Sequencing and Timing (1 pt.)
1) Kitchen Set up (5 Minutes)
2) Verbal sequencing of task (3)
3) Cooking (10)
4) Eating (12)
5) Washing Dishes (5)
6) Dry dishes (2)
7) Put dishes away (3)
 8) Discuss what she enjoys, things that make her happy, topics etc. (5)
9) Cut out paper for stones (3)
10) Write sayings on stone (8)
11) Glue paper to stones (3)
12) Put stones into bucket to bring back to room (1)
vi. Required Actions and Performance Skills
1. For Each individual activity list the specific Occupation s, Client Factors, Performance
Skills, and Performance Patterns you are addressing (these must be listed in the Purpose
section) and how you are addressing them. (4 pts.)
Scrambled Eggs:
Occupations:
- IADL’s: Managing the meal prep activity will work towards independence or decreased
assistance.
Client Factors:
- Muscle Power: Client will need to gauge appropriate muscle exertion to complete the
activity.
- Muscle Endurance: Client will be standing as much as bearable, which will in turn focus
on endurance of standing instead of becoming stiff while sitting.
Performance Skills:
- Reaches: Client will need to reach for ingredients and objects during cooking task while
maintaining balance.
- Stabilizes: Client will efficiently stabilize objects to transport them to the areas in which
they are needed without loss of balance.
- Moves: During cooking activity client will move through environment and finish task
successfully.
- Paces: Client will need to pace the activity in order to have all dishes prepared at the
same time.
- Navigates: Client will use functional ambulation device to naviga te through kitchen
environment during cooking activity.
- Endures: Because client will be standin g for much of the activity, her endurance will be
enhanced through the various tasks within cooking.
Performance Patterns:
 - Routine: Client had a previous routine of cooking for herself, this will help her to return
to this level of independence.
- Role: Client took care of herself with other and desires to return to this. By cooking,
client is more apt to return home and be independent in eating/meal prep tasks.
Happiness Stones:
Occupations:
- Leisure: client’s participation of leisurely activities has decreased as time has been spent
in acute care. This will allow client self -expression through a crafting activity she enjoys.
Client Factors:
- Emotional: Client will focus on positive emotions during activity instead of feelings of
anxiousness or depression.
- Muscle Power: Client will need to exert the appropriate force when cutting or gluing to be
successful in the activity.
- Muscle Endurance: Client will be standing for the majority (as tolerated) throughout the
activity. She will enhance her endurance through the various attempts at maintenance of a
standing balance while performing a functional activity.
Performance Skills:
- Reaches: Client will need to reach for other supplies in order to complete the task.
- Paces: Client will need to pace through the activity to sequence it properly and finish the
activity in a effective manner.
- Endures: As client will be standing for activity, endurance of standing a nd balance will be
challenged.
Performance Patterns:
- Role: Working on fine motor, sequencing and emotional regulation tasks will allow client
to better participate in other roles that are needed throughout her engagement in daily
occupations.
vii. List any Context and Environmental Factors that are associated with the activity. (1 pt.)
Context:
- Personal: Client is working towards goals they she set and that she has the motivation to
engage in activity for achievement towards these goals.
- Temporal: Client usually has therapy in the afternoon when she has been off her feet
which would make them rested and ready for therapy.
 Environment:
- Social: By working towards these goals, her legs are getting stronger in matters of
endurance and duration of WB. Improvement in weight bearing will allow client to
participate in more social activities.
viii. List the Type of Intervention this activity is. (1 pt.)
Activities: Client engages in activities as a type of intervention to enhance her level of
independence and improve upon her skills. These activities during therapy are meaningful and
relevant to the client and her goals.
Total Points: All above must be present and appropriate, written professionally, minimal to no grammar/writing
errors.
Additional Treatment Ideas: (Make a brief list (6 or more) of all other treatment ideas you would use when working with this __/3 pts.
individual.
1) Happiness Jar- Sticks that have an activity the client enjoys
2) Hold on/let go hands- hands that have things to hold onto and things to let go of
3) You are Jar- Jar filled with paper, You are……
4) Laundry sorting task- sorting laundry to be independent
5) LE dressing- dressing ADL
6) Weight training- shoulder weight training to increase MMT score
Culturally Relevant: Provide your rationale for how this treatment plan is culturally relevant (1 pt.). ___/1

This treatment is culturally relevant as the goals are client centered. Because the client was able to choose her own goals and was
motivated to work towards them, treatment is centered around the client’s cultural values and cultural beliefs, etc. The treatment is
culturally relevant as the client choose the meal she desired to make. It also is addressing the importance of mental health and mental
well-being in a facility that primarily focuses on physical features and strengthening.
Evidence Based Practice: ___/3.5
Provide the APA Citation (.50 pt.) for 1 EBP article that you feel provides an appropriate treatment method/Activity for this
diagnosis, describe the treatment method and why you chose it (1 pt.) and how you used it in your treatment (1 pt.).

Leibold, M. L., Holm, M. B., Raina, K. D., Reynolds, C. F., III., & Rogers, J. C. (2014). Activities and adaptation in late-life
depression: A qualitative study. American Journal of Occupational Therapy, 68, 570–577. http://dx.doi.org/
10.5014/ajot.2014.011130

This qualitative study viewed the activity choice between the geriatric population who had been diagnosed with depression. The study
used a semi structured interview with community dwelling participants. The major themes that emerged from the interview with 27
participants were as follows: “ 1. Established habits and commitments kept me engaged. 2. Some activities were still gratifying. 3.
Family and friends nudged me into action. 4. I gotta keep going. 5. Distraction and escape took me away from my situation.
6. I’m hiding my depression from other people (p. 572).” Through this interview, implications for practice as noted by this article
include client-centered assessment interviewing, identification of potentially compromised activity patterns, and implemention of
stretegies of pre-arranged activities, supportive activities and adaptive strategies.

I choose this article because it highlights the importance to Occupational Therapy in promotion of client-centered treatment as well as
the importance of engagement of occupations. They highlighted that many people who have this diagnosis do not seek treatment and
therefore highlight the importance of treating or acknowledging these symptoms in therapy.

I used this in my treatment as the facility I am doing fieldwork at is very physical health focused. Many of the clients has secondary
diagnoses such as these but they are going untreated in therapy. I think that addressing these factors and diagnosis during treatment is
extremely important instead of looking strictly at the physical aspects. Occupational Therapy considers the person as a whole and
needs to address these areas.

Make sure you discuss why this treatment method would help the patient/how it will be used in the treatment you are providing.
Review this Article with your Fieldwork Supervisor and describe how the discussion went? (1 pt.)

The discussion went well. She mentioned that it was difficult to address mental health aspects in therapy within this facility due to the
limited resources. She was interested in ways to promote mental health well-being among the patients and more than one have a
similar diagnosis. She also mentioned that she would be curious what they could do for mental health in their facility with the
resources they did have.
Health Professionals: __/2
Identify the Health Professionals that would be important to collaborate with in regards to this patient (more than 2) (.50 pts.) and
discuss why (.50 pts). Identify when you would refer to these health professionals for consultation and intervention and the process
you would follow. (1 p
- Psychologist: Important to discuss with as the client has a history of anxiety and
depression that decrease her overall well-being and quality of life. I would refer this
individual once diagnosis was apparent. I would consult with the patient to see if seeing a
psychologist was something she would consider, then contact one that was recommended
or the most convenient for her.
- Physician: Important to discuss with as the client progresses through therapy and is
moving towards going home. I would consult with this health professional from the
beginning and work with them throughout the therapy process. I would contact the
physician for any questions regarding the patient. I would recommend a check -up or
appointment when significant improvement has been made or when another concern
arises.
 - Dietitian: Important as client is considered obese. It would be beneficial to refer to a
dietitian to consult in healthy eating and a plan of action. I would refer for consultation
after talking with the client and educating on the risks of being obese. The process would
begin with contacting a dietitian that is convenient to the client and helpin g to schedule
the first appointment.
Further Evaluation: __/2
Identify when you would recommend to the OT the need for additional evaluation (.50 pt.) and describe why (.50 pt.)

I would recommend an additional evaluation if the results of treatment have tapered off or the client has stopped progressing. I would
also consider referring client when goals have been met to establish new goals. Whenever the child stops to make progress it would be
beneficial to refer the client to the OT to ensure no other difficulties or deficits have developed.

Community Resources: ___/2

Identify any community resources that would be valuable to this client (1 pt.) and describe why (1 pt.)

Public transportation: This would be beneficial until client is able to drive and is termed safe to operate a vehicle.
Gym Programs: Help to loose weight as a preventative measure and increase strength in legs post surgery
Social programs: Increasing social participation will help to decrease feelings of loneliness, depression and anxiety.

Outcomes: Refer to Table 9: Outcomes on page 34 and 35 in the OTPF. Identify the primary outcomes (minimum of 2) your client ___/4
will have achieved as the result of the therapy you provided. Describe how they will have meet these outcomes and why you chose
these outcomes.

Improvement: Client will have improved upon skills that she has maintained. However, as a result of therapy she will improve upon
skills that have regressed as a result of bilateral knee or other secondary diagnosis.
Quality of life: Increasing the patients quality of life by making her the most independent possible is the main goal of therapeutic
intervention. Client will have achieved increased quality of life as her independence increases.

Treatment Plan Total Points: __/50

Part II Total Points ____/60