Diagnostisch rapport casus Sven ergotherapie jaar 1 kwartaal 2, cijfer: 10
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Course
Methodisch handelen - Methodiek
Institution
Hogeschool Rotterdam (HR)
Bij de studie ergotherapie moet je in leerjaar 1 kwartaal 2 een diagnostisch rapport schrijven. Dit diagnostisch rapport gaat over de casus Sven. Sven is jongen met cerebrale parese. Ik heb voor dit diagnostisch rapport een 10 gekregen.
Door: Ilse van Zantvliet
Studentnummer: 0946727
Klas: ERG-1D-18
,Inhoudsopgave
Algemene gegevens............................................................................................................3
Hulpvraag...........................................................................................................................4
Begeleidende brief..............................................................................................................5
Afgenomen assessments.....................................................................................................5
Conclusie assessments........................................................................................................6
Resultaten uit het kennismakingsgesprek.....................................................................................6
Resultaten uit de COSA.................................................................................................................6
Resultaten uit de MOHO-intake....................................................................................................6
Resultaten uit vrije observatie......................................................................................................7
Ordening in inhoudsmodel..................................................................................................7
MOHO...........................................................................................................................................7
Ergotherapeutisch probleemdefinitie...............................................................................10
Globaal behandelvoorstel.................................................................................................10
ADL-training................................................................................................................................10
Transfer.......................................................................................................................................11
Bijlagen.............................................................................................................................11
Afgenomen assessments.............................................................................................................11
MOHO-intakelijst........................................................................................................................11
COSA...........................................................................................................................................20
Vrije observatie...........................................................................................................................22
Doelmatigheid...................................................................................................................22
Verantwoording assessments......................................................................................................23
COSA.............................................................................................................................................23
MOHO-intakelijst..........................................................................................................................23
Vrije observatie.............................................................................................................................23
Reflectie......................................................................................................................................24
Wat ging er goed?.........................................................................................................................24
Wat ging er minder goed?............................................................................................................24
Wat zou je volgende keer anders doen?......................................................................................24
Andere bijzonderheden?..............................................................................................................24
Leerpunten?.................................................................................................................................24
....................................................................................................................................................24
Bronvermelding...........................................................................................................................24
, Algemene gegevens
Cliëntgegevens
Naam: Sven Petersen
Geboortedatum: 20-08-2004
Geslacht: Man
Adres: Hof van Delftlaan 304
Telefoonnummer: 015-1234567
BSN: 45678901
Verzekeraar – polisnummer: Agis, 3456789
Huisarts: Dhr. A. Verbeek
Verwijzer
Naam:
Functie: Revalidatiearts de Regenboog
Werkzaam bij: De Regenboog
E-mailadres: Bloem@deregenboog.nl
Telefoonnummer: 015-4567890
Werktijden: Di, do, vrij 08.30-17.00 u.
Datum verwijzing: 27 december 2018
Medische diagnose: Cerebrale Parese
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