Progress Report Overview

Student: Adriana Turtura & Joshua Wilson

Activity: Jordan Rutherford

Start Time: 02/20/2024 10:34:27

End Time: 03/27/2024 16:34:59

Total Time: 11:55:42

Actions

Note at 03/27/2024 16:27:44

Jordan Rutherford Documentation
Student: Adriana Turtura & Joshua Wilson
Activity Start: 02/20/2024 10:34:27
Activity Completion: 03/27/2024 16:34:59
Activity Completion: 11:55:42

Patient Data

Patient: Jordan Rutherford DOB: 06/14/1945

Age/Sex: 78 yo MR#:

Notes

Note at 02/20/2024 10:19:23

Occupational Therapy (OT) SOAP Note

Basic Information

Date:

02/20/2024 10:19:23

Author:
Current User

Location:
River Bend Home Health

Patient name:

Jordan Rutherford

Diagnosis

Bilateral, intermediate, age-related, wet macular degeneration

Precautions/medical history:
PMH:
F51.01 Primary insomnia
H35.32 Exudative age-related macular degeneration
I10 Essential (primary) hypertension
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site

Precautions/contraindications:
None

Medications:
Ramelteon 8 MG Oral Tablet [Rozerem] - Dose: 8mg QHS
0.15 ML Methotrexate 50 MG/ML Prefilled Syringe - Dose: 7.5mg QW
24 HR Metformin hydrochloride 500 MG/saxagliptin 5 MG Extended Release Oral Tablet - Dose: 500mg BID
Amlodipine 10 MG / BZP hydrochloride 20 MG Oral Capsule - Dose: 10mg QD
FIBSOL (Lisinopril) 20mg Tablet - Dose: 20mg QD

Treatment date:

2/27/2024

Start time:

9am

End time:

11am

Subjective
Occupational Profile:
Client is a single 79-year-old who is seeking low-vision OT services to maintain living safely and independently in their home after
recently being diagnosed with bilateral, intermediate, age-related, wet macular degeneration. Client lives alone with their cat. Client
seeks to continue grocery shopping, medication management, online banking, and using communication technology, e.g., iPhone
and home computer. Additionally, they would like to continue watching their favorite television programs.

Success: They are cognitively intact, are technologically proficient, and fiscally well to do.

Barriers: Client does not have any extended family or friends living nearby.

-Occupational history:
Client is a retired information technology specialist. They live alone in a single-level house with their cat in a small rural community
outside of Yakima, WA. Client manages hypertension and diabetes with medication. They also take medication to treat intermittent
rheumatoid arthritis flare-ups and chronic insomnia. Client is not married and does not have any children.

-Social history:
Client values being in nature because it provides time to clear their mind. Before their vision became impaired, they enjoyed hunting
and fishing with their buddies.

Subjective:
- Patient concerns/priorities: Client is primarily concerned with maintaining their independent living status. They report a loss of
central vision that affects their ability to read food and prescription medication labels, and perform close-up work on their
electronic devices. Client wishes to prioritize addressing these IADLs first. Additionally, they report an increased fear of falling which
limits their participation in activities related to social and consumer interactions.

Objective

Vital signs:
74 bpm, 118/94 mmHg, Spo2 94%, Respiratory rate 13breaths/min

Pain assessment:
Client is person-oriented and alert without signs of pain or distress. Client’s cognitive skills are intact.

Physical environment:
single-level ranch home
- Exterior entrances & exits: One-step walkway from driveway to front door paved, uncluttered. Two-step covered porch to the
entryway with handrails.
- Interior doors, stairs, hallways:
Lighting and controls: overhead lighting, controls on both ends of hallway easily accessible.
Door thresholds: smooth transitions between hardwood surfaces
Door width: 28 inches all interior doors, in good condition
Knob and hinge types: all interior doors have ball door knobs and plain butt hinges, in good condition.
Floor surfaces: hardwood floors throughout home. No level changes.
Hallway width: 36 inches, uncluttered
Types of stairs: None.
Rail(s): None.

- Bathroom(s):
Lighting and controls: Overhead and vanity lighting in master and guest bathrooms. Controls
easily accessible.
Tub/shower and controls: Master bath has standing shower and guest bath has tub/shower combination with curtain and liner.
Temperature control knobs and diverter pull operational.
Sink/basin and controls: Temperature control knobs and drain stopper operational.
Under sink hot water pipes covered: Enclosed in cabinet.
Reaching overhead shelf / below basin: No overhead shelf in front of basin; swinging drawers for
toiletries located to left and right of basin cabinetry
Toilet height: 16 inches floor to seat
Flush control: Duel flush control buttons on the cistern
Ground fault circuit interrupter (GFCI) outlets: Located near basin.

- Kitchen:
Lighting and controls: Overhead, incandescent. Controls easily accessible.
Sink and counter heights: Single bowl, stainless steel drop-in kitchen sink and counter located
34 inches from floor.
Wall and floor storage shelf heights: Lowest shelf 6 inches from floor; highest shelf 77 inches
from floor.
Under sink hot water pipes covered: Enclosed in cabinet.
Surfaces for hot items near range/stove: 18 inches countertop to right of stove.
Location and condition of stove controls: Controls along back of stove; red=on-black markings are in good condition
Ground fault circuit interrupter (GFCI) outlets: To left of sink.

- Living, dining, bedroom:

Furniture heights to allow sitting/standing/transfers: Sofa and reclining armchair
Chairs with armrests: Six dining chairs, none with armrests.
Operation of environmental controls (lighting) from bed, chair, and sofa: Lighting controls
located left of the doorway on the same wall as the seating area.
Access to closets: Coat closet and bedroom closets with sliding doors
Window operation: Sliding vinyl windows with screens

- Laundry:
Access to wash/dryer: Laundry detergent and basket located on a shelf above washer and dryer.
Operation of washer/dryer: Controls along the back of appliances.
Access to cleaning supplies: Mop and broom lean against wall next to the washer.
Safety
Smoke detectors: In kitchen and both bedrooms and hallway; battery charge light on.
Carbon monoxide alarms: Located in kitchen and in hallway between two bedrooms.
Fire extinguishers: One under sink in kitchen
Thermostat controls: Located in hallway near lighting controls.
Water heater temperature settings >120 degrees: 120 degrees
Emergency plan (fire, gas leak, power outage): Two exits from house (front and back); both
bedrooms have egress through window. Back door patio occupied by bbq grill and table.

- Basement: N/A
- Safety:
Smoke detectors: In kitchen and both bedrooms and hallway; battery charge light on.
Carbon monoxide alarms: Located in kitchen and in hallway between two bedrooms.
Fire extinguishers: One under sink in kitchen
Thermostat controls: Located in hallway near lighting controls.
Water heater temperature settings >120 degrees: 120 degrees
Emergency plan (fire, gas leak, power outage): Two exits from house (front and back); both
bedrooms have egress through window. Back door patio occupied by bbq grill and table.

- Computer workstation:
Desk: L-shaped, adjustable-height computer desk (23.6"D x 63"W x 26.9"H)
Chair: swivel adjustable-height chair (27’’L x 27.76’’W x 44’’H)

Occupational Performance:
- ADL performance: Client is independent with self-care needs (e.g., feeding, grooming, dressing, bathing, and toileting).
- IADL performance: Client is independent with pet care and simple meal preparation in the microwave. They do not drive; instead,
they take ride-sharing services to the grocery store, one time per week. They also hire contract services for weekly housekeeping
and yard care.
- Health management: Client manages hypertension and diabetes with medication. They also take medication to treat intermittent
rheumatoid arthritis flare-ups.
- Rest and sleep: Client manages chronic insomnia with medication.
- Transfers: N/A
- Functional mobility: Slower walking associated with visual impairment, and an increased risk of developing mobility disability as
macular degeneration progresses.

Performance Skills/Actions/Movements:
Visual Acuity
Client visual acuity exhibits difficulty reading small print and difficulty with low contrasts.
• Pupil size and Symmetry sub-test: eyes were symmetrical and typical pupil dilation and constriction.
• Eye Dominance sub-test: view imaged with left eye three times.
• LeaNumbers Acuity Test Chart: Client exhibited 20/500 Snellen score and 1/25 for metric score.
• Warren Text Card: Snellen score 20/320 and print size read score 6.3M
• LeaNumbers Low Contrast Acuity Flip Chart: Client scored 1.25% contrast level.
Oculomotor Control Assessment
Client's Oculomotor Control exhibits difficulty tracking objects near and at the midline.
• General appearance: Symmetrical eyelids, Position of eyes in primary gaze: R-eye deviated inward, L-eye deviated outward, Head
position in primary gaze: Turned to left, No Nystagmus.
• Corneal Reflection: Both eyes had reflection in center of pupil.
• Tracking Eye Movements: Both eyes track vertically, horizontally, and diagonally.
• Convergence: Unable to follow the target inward.
• Diplopia-Tropia/Phoria: Both eyes moved outward.
Visual Fields Assessment
Client's Visual Field had trouble identifying blind spots with R eye covered.
• Two-Person Kinetic Conformation Test: L & R eye detected light from Left, Right, Superior, and Inferior directions.
• Damato Campimeter: Client had to lean left when R eye was covered. Client has a blind spot with both eyes.
Visual Attention Assessment
Client visual attention accuracy declined as the assessment sheets became complex or crowded. Client was unable to accurately
identify all seen/located targets on subtests.
• Letter Search Simple: 30/40 targets= 75% accuracy in 7 minutes 30secs.
• Word Search: 20/30 targets= 67% accuracy in 6 minutes.
• Random Plain Circle Simple: 10/20 targets= 50% in 4 minutes.

Computer Workstation Ergonomics

Assessed client’s workstation ergonomics for optimal comfort and performance. Adjusted chair seat and back of the chair so that
client’s back was supported by the backrest, elbows bent 90 degrees, forearms horizontal, thighs horizontal with a 90-110 degree
angle at the hip, and feet fully supported and flat on the floor. Also, moved frequently used items (keyboard and mouse) within easy
reach.

Client Factors:
Client’s visual acuity, visual attention, visual field functions, and oculomotor control are impaired due to wet macular degeneration.
This affects the client's visual awareness of their environment at various distances for functioning. Proprioceptive functions are
slightly impaired making it difficult for client to be aware of their body position in space. Client did not report any
neuromusculoskeletal or movement-related functions.

Assessment
 Summary:
Client’s vision is impaired to the degree that they are no longer able to drive and therefore depend on Internet banking to manage
their finances. However, their loss of central vision makes using electronic devices such as an iPhone and a computer challenging.
Additionally, client reports difficulty reading medication and food labels.

Functional Problem Statement:

Client requires modified assistance to independently manage medications and perform online banking tasks because of vision
impairment.

Rehab Potential:
Client’s background in information technology and intact cognitive skills indicate good potential for training in low-vision assistive
devices and technology. Additionally, client's motivation to retain independence indicates good potential for positive outcomes.

Potential Benefits to Receiving Interventions:

Client would benefit from skilled instruction in the use of Scrip Talk to increase medication safety and low vision aids for computer
use such as screen magnification and reader programs to maintain financial independence.

Potential Risks Associated with not Receiving Interventions:

Without intervention, the client is at risk of taking their medication incorrectly which can result in severe harm, disability, and even
death. Additionally, the client is at risk of losing their independence which is a common cause of depression in older adults.

Plan

Overview of Intervention Plan: Find ways to adapt the demands of medication and financial management activities to support
performance in the client's home.
Frequency: 2x per week
Duration: 60 mins
Location: Home health
Foci of Services: Occupational Therapy

Targeted Outcomes: Occupational performance

Outcome 1: Client with impaired vision will manage their medications safely with modified independence using audible medication
label technology.
Outcome 2: Client with impaired vision will navigate the web and perform online banking tasks with modified independence using
screen reader software.

Goals:
LTG 1: Client will use Scrip Talk device independently by end of 4th treatment session.
STG 1: Client will use Scrip Talk device with 3 or fewer verbal cues by end of 2nd treatment session.
STG 2: Client will use Scrip Talk device with 1 or fewer verbal cues by end of 3rd treatment session.
Approach to Intervention: Modify/adapt
Type of Intervention: Assistive device

LTG 2: Client will use screen reader software independently by end of 4th treatment session.
STG 1: Client will use screen reader software with 3 or fewer verbal cues by end of 2nd treatment session.
STG 2: Client will use screen reader software with 1 or fewer verbal cues by end of 3rd treatment session.
Approach to Intervention: Modify/adapt
Type of Intervention: Assistive technology

Charges:
97165 - OT evaluation

If other, describe

97537 - Ergonomics Assessment Consulting

Electronic signature:

Annie Turtura & Josh Wilson