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Diagnostisch rapport Sven met feedback - 7,2
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Diagnostisch rapport Sven petersen met feedback, cijfer 7,2
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DIAGNOSTISCH RAPPORTSVEN PETERSEN
CEREBRALE PARESE
Madelon Moorman
HOGE SCHOOL ROTTERDAM ERGOTHERAPIE
,Inhoudsopgave
Gegevens................................................................................................................................................3
Hulpvragen.............................................................................................................................................4
Diagnostisch rapport Sven Petersen.......................................................................................................4
Diagnostiek.............................................................................................................................................4
Resultaten kennismakingsgesprek......................................................................................................5
Resultaten COSA.................................................................................................................................5
Resultaten vrije observatie aan- en uitkleden....................................................................................5
Resultaten vrije observatie concentratievermogen............................................................................5
Ordening CMOP-E inhoudsmodel...........................................................................................................7
Persoon..............................................................................................................................................7
Spiritualiteit:...................................................................................................................................7
Affectiviteit:....................................................................................................................................7
Cognitie:.........................................................................................................................................7
Fysiek:.............................................................................................................................................7
Handelen............................................................................................................................................7
Zelfverzorging:................................................................................................................................7
Productiviteit:.................................................................................................................................7
Vrije tijd:.........................................................................................................................................7
Omgeving...........................................................................................................................................8
Fysieke omgeving:..........................................................................................................................8
Institutionele omgeving:.....................................................................................................................8
Culturele omgeving:...........................................................................................................................8
Sociale omgeving:...............................................................................................................................8
Ergotherapeutische probleemdefinitie...................................................................................................9
Behandelvoorstel...................................................................................................................................9
Bijlage...................................................................................................................................................11
Kennismakingsgesprek.....................................................................................................................11
Toelichting kennismakingsgesprek...............................................................................................11
Uitwerking kennismakingsgesprek...............................................................................................11
Samenvatting kennismakingsgesprek...........................................................................................12
COSA.................................................................................................................................................12
Toelichting COSA..........................................................................................................................12
Uitwerking COSA 6y......................................................................................................................13
Samenvatting COSA......................................................................................................................21
, Vrije observatie aan- en uitkleden....................................................................................................21
Toelichting vrije observatie aan- en uitkleden..............................................................................21
Uitwerking vrije observatie aan- en uitkleden..............................................................................21
Samenvatting vrije observatie aan- en uitkleden..........................................................................23
Vrije observatie concentratievermogen...........................................................................................23
Toelichting vrije observatie concentratievermogen.....................................................................23
Uitwerking vrije observatie concentratievermogen.....................................................................23
Samenvatting vrije observatie concentratievermogen.................................................................24
Inhoudsmodel CMOP-E.....................................................................................................................24
Toelichting CMOP-E......................................................................................................................24
Samenhang assessments + Inhoudsmodel.......................................................................................24
Reflectie............................................................................................................................................25
Gegevens
Persoonsgegevens cliënt
Achternaam Petersen
Voornaam Sven
Geboortedatum 20-08-2004
Geslacht ☒ Man ☐ Vrouw
Burgerlijke staat/woonsituatie Woont bij ouders, 1 jongere broer
Adres Hof van Delftlaan 304
PC/Woonplaats 2611 XX Delft
Telefoonnummer 015-1234567
Zorgverzekeraar Agis, 3456789
BSN 45678901
Medische gegevens cliënt
Medische diagnose(n) Bilaterale, spastische cerebrale parese
Hulpvraag op het gebied van ☒ Wonen/ zorgen (zelfverzorging)
☒ Werken/ leren (concentratie op school)
☐ Vrije tijd/ spel
Toelichting hulpvraag/ reden verwijzing Sven wil graag zelfstandig worden in zelfzorg.
Hij wil zichzelf kunnen aan- en uitkleden.
Daarnaast wil Sven zich beter kunnen
concentreren op school.
Andere betrokken hulpverleners/ instanties Kinderfysiotherapeut, kinderrevalidatiearts
Gegevens ergotherapeut
Naam Madelon Moorman
Functie Ergotherapeut bij Ergotherapie Rotterdam
E-mail adres Madelon.m@hotmail.com
Telefoonnummer 0641620020
Bereikbaarheid Ma, woe, do, vrij 08.00-16.00 u.
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