These limitations will impact length and level of difficulty during treatment and evaluation sessions,
and will also impact scheduling of sessions as well as breakdown of appointments.
3. Being able to independently bathe and manage bowel and bladder (i.e. self-catheterization of
bladder) - so doesn't have to rely on mother doing these tasks.
4. Client would also like to get back to driving, working, going back to school, and ability to live I in
future if he chooses to move out of his parent's house eventually. - these are not goals I will be
addressing with him at this time however.
Articles -
This article supports the use of the SCIM as a functional measurement in
post-acute rehab program for people with SCI.
https://www.nature.com/articles/sc2009140
MOVEMENT FUNCTIONS -
- how is his invoulntary movement reactions? -
can he do body adjustment reactions or postural
reactions?
OTHER FUNCTIONS:
- How is his blood pressure? Does he know how
to recognize and respond to Autonomic
Dysreflexia?
Observe Chart doing part of his typical morning I would use this opportunity to observe and
routine - specifically - LE dressing evaluate many of the above mentioned motor
and processing skills that need to be further
assessed. By having him perform his morning
dressing routine (LE only), I can observe his
functional mobility around his room (to gather
his clothing - unless his mother is doing this for
him), I can observe how/if he is transporting or
carying things from one location to another, and
how he is manuvering w/c around space (is he
pushing or pulling, or using hand holds on the
wheels, is he using both arms equally, etc.)
This task will also allow me to evaluate his
pacing of the activity, and begin to determine
level of assist he may need. I would like to
observe him first doing the task with his
mother's assistance (how they typically do it),
and then I would like to observe him attempting
the task (pants, shoes and socks - I would skip
underware in this initial meeting if he were
feeling uncomfortable) on his own, to determine
a baseline. During this observation, I can also
strike up a conversation with him (if he is able to
effectively multitask) to gain more background
information about his interests, concerns, life
history (basic), and begin to build a therapeutic
relationship with her, as well as begin to get her
"buy in" to the therapy sessions. Later on during
the observation, I would also (if appropriate)
begin to provide feedback, guidance and cuing
to see how/if he responds. I would also try to
introduce some simple strategies for him to try
as the activity comes to an end.
Method/Tool Rationale/What is being Assessed
The classification code is based on the lowest level in the three above
listed sections; all 3 sections are justified for High Complexity,
therefore, the code should also be High Complexity (97167).
2. LTG:
Within 10 weeks, client will I dress LE by utilizing AE and PEO, Biomechanical & Rehab
compensatory strategies and maintaining safety, within a 40
minute timeframe.
2a. STG:
Within 7 weeks, client will dress LE with Mod A while Biomechanical & Rehab
utilizing AE and maintaining safety, within a 35 minute
timeframe.
2b. STG:
Within 4 weeks, client will increase UE strength needed to Biomechanical & Rehab
bring foot up to opposite knee utilizing AE and maintaining
safety.