Activities of Daily Living (Rehab)


System
UnitID 1 1
Date 2001/5/14 2001/5/14
Started 13:58 14:29
Finished 14:29 14:54
Client
Surname Lake  Arnold 
GivenName Ruth  Luke 
Gender Female  Male 
DateofBirth 8-6-37  17-2-76 
Address 6 Poole St, Ardross.Perth. WA  34 Mend St, Geraldton. Perth. W.A. 
PhoneContact (08) 96789432  (08) 92345676 
MaritalStatus Single,  Single, 
LiveWith Alone,  Alone, 
Accomodation Unit,Rental,  Flat,Rental, 
PreferredLanguage English  English 
AssessmentLocation Rehab Facility,  Rehab Facility, 
AssessorContact Helen Deans. O.T. (08) 5678934  Jack Hardy(08) 9876547 
Medical History
DrGP Dr Louise Carter  Dr Greg Gray 
DrContact (08) 97654334  (08) 96421359 
Diagnosis Joint Replacement,  Amputee, 
DiagnosisOther Right Hip  Right above-elbow amputee 
Disability Muscle weakness & decreased range  Loss of dominant right hand 
Medication Analgesics,Anti-Coagulants,  Analgesics, 
MedicationOther    
SpecialisedTreatments   Scar Management,Prosthesis/Training, 
MedicalNotes Weight-bearing with cruches  Wound healing well 
Locomotion
Walking Yes  Yes 
Wheelchair No  N/A 
StepsStairs No  Yes 
LocomotionAids Crutches,   
AidOther    
Orthosis    
Prosthesis   Yes 
LocomotionStatus Safe  Safe 
Wh/Chair Skills
Slopes    
RoughGround    
Kerbs    
Step    
RearWheelBalance    
TransferWhChintoCar    
Transfers
BedMobility Independent,  Independent,Independent,Assistive Devices, 
ChairWheelchair Independent,   
Bed Independent,  Independent,Assistive Devices, 
BathShower Needs Assistance,  Independent,Assistive Devices, 
Toilet Independent,  Independent,Assistive Devices, 
Car Needs Assistance,  Independent, 
FloorChair   Needs Assistance 
Bathing
Bath Needs Assistance,  Independent,Assistive Devices, 
Shower Needs Assistance,  Independent,Assistive Devices, 
Personal Hygiene
Toileting Needs Assistance,  Independent,Assistive Devices, 
BladderBowel Bladder/Continent,Bowel/Continent,  Bladder/Continent,Bowel/Continent, 
Grooming
Haircare Independent,  Independent,Assistive Devices, 
CleanTeeth Independent,  Independent, 
Shave Independent,  Independent, 
ApplyMakeup    
Nailcare Independent,  Needs Assistance, 
Dressing
UpperLimb Independent,  Needs Assistance,Assistive Devices, 
LowerLimb Needs Assistance,Assistive Devices,  Independent, 
Fastenings Needs Assistance  Needs Assistance 
Eating
Eating Independent,  Independent,Assistive Devices, 
Drinking Independent,  Independent,Assitive Devices, 
ChewSwallow Independent,  Independent, 
Services
AlliedHealth Occup/Therapy,Physiotherapy,  Occup/Therapy,Physiotherapy,Nursing, 
OtherAlliedHealth    
LiveinCommunity Yes  Yes 
Carer Yes  Yes 
CarerMaintainSupport Yes  Yes 
CommunitySupport Home-visit,  Transport,Home-visit, 
CommunityFacilities    
ResidentialCare    
ResidentialCareOther    
Notes O.T. to supply assistive devices  Motivated for prosthesis training