Follow the easy step-by-step process of this note to learn how to accurately summarise client needs or goal, person-centred assessment and observations, including planned interventions in on document. Practice will improve your record-keeping skills.
Pt C suffered a stroke and has struggled with ADLs. Has a carer who comes in once a day to
help him with bathing. Struggles with memory and concentration, especially with retaining
new information and his memory and concentration. Pt C said his memory got worse 2/3
years ago before the stroke. He still remembers normal things, that he does regularly like
how to make a phone call, but complex things can be forgotten. Does not drive, but can ask
his son to take him to appointments.
Objective
An ACE III Cognition screen was conducted to check the amount of information Pt C can
retain and/or remember. Pt was distracted and seemed to concentrate at intervals. Prompts
were needed to support memory tasks.
Analysis
Pt C is unable to participate in his bathing due to cognitive deficit and lack of motivation, so
his carer was advised that he would require a prompt to do more for himself. At bath time,
the carer can remind him to wash himself, and a note was made and stuck on his fridge by
OT as a reminder to ‘Do exercises’, since he forgets to do them. He could remember most of
what he did in the past and knew where he was, as well as the time and date. He said that
he remembers to take his medication. Hi information processing was slow most of the time.
Pt C could repeat complex words and sentences, and identified all the images shown to him
but could not recollect three words said earlier.
This indicates that when given a lot of instruction at once, he tends to forget. However, he
said that things were not quite right with his memory before the stroke.
Plan
• Refer to the memory clinic as cognition is not within our remit.
• Details and outcome of today’s assessment will be sent to the memory clinic, so they
can assess Pt C for any future help he would need with his memory.
• Discuss referral with son.
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