How to Report on Client Status
How to Report on a Client's Status
During interprofessional team meetings (or "rounds"), Individualized Education Program (IEP) meetings, or communications with your clinical instructor, you may be asked to provide a concise summary of the client's medical status or therapy progress. Be prepared!
A strong summary typically includes:
Patient Background: Key medical history and reason for therapy
Current Status: Functional abilities, challenges, and recent progress
Intervention Details: Treatments or techniques used, along with responses
Goals Moving Forward: Next steps in therapy and recommendations
The type of information you report depends on the circumstances under which you are reporting. Here are two examples:
EXAMPLE 1 (to your clinical instructor prior to acute OT evaluation, based on chart review):
"Mr. Richardson is a 45-year-old man who underwent a spinal fusion with laminectomy yesterday. He has a history of bilateral knee surgeries and diabetes. He lives alone and works at a bank. He has state health insurance BCBS. He was referred to OT/PT for evaluation and treatment because he is having difficulty getting out of bed and has no one to assist him at home. I anticipate he will need education on exercises, proper positioning, and potentially adaptive equipment in preparation for returning to work. He will not likely be able to go back to work for at least 4 weeks. The doctor has cleared him to get out of bed with therapy. My plan is to see if he can get from the bed to the sink to wash his face."
EXAMPLE 2 (during an interdisciplinary meeting after OT has been initiated):
"Mr. Richardson is a 45-year-old man who underwent a spinal fusion with lami about 5 days ago. He initially needed a lot of encouragement to get out of bed due to severe back pain, but he is now able to get up on his own and tolerate sitting in the chair for 30 minutes at a time. He is concerned about going home alone, but he can complete his dressing activities modified independently and demonstrates the necessary skills to be able to get around his house safely and make simple meals. He wants to get back to work as a bank teller as soon as possible. I anticipate he will be ready to return to light duties at work in another 2-3 weeks with a 3-in-1 bedside commode, but he may benefit from an occupational therapy worksite evaluation for potential environmental modifications. He is aware that he should not be doing any heavy lifting for several weeks, and he is independent with his exercise program. He does not need any equipment at this time. His chart says that he is likely to discharge home today or tomorrow."
Tips for presenting:
Speak with confidence and professionalism.
Use good body posture and gestures.
Make eye contact.
Allow opportunity for questions.
Do not elaborate excessively. Give key points.
Include meaningful tidbits from the patient's occupational profile.
If client is an inpatient, focus on discharge plans, support network, and equipment needs.