HISTORY OF PRESENT ILLNESS:

The client reports that they originally sustained the injury on when they fell and injured their wrist. They were evaluated at Urgent Care/ER where X-rays identified a left distal radius fracture. They were placed in a splint, referred to Dr. , and surgery was recommended. The patient presents to hand therapy today for their post-operative initial evaluation and treatment.

DX/SURGERY:

DOS:

PRIMARY COMPLAINTS:

PRIOR FUNCTIONAL STATUS:

CURRENT FUNCTIONAL STATUS:

See "Client Information Sheet" for activities that patient reports having difficulty with. Client reports difficulty in the following activities:

Occupation:

Social Status:

PAIN:

Pain location:

At worst: 12345678910/10

Current: 12345678910/10

At best: 12345678910/10

Pain description:

Pain Follow-up Plan:

PATIENT GOALS:

OBJECTIVE FINDINGS:

Handedness: RightLeftAmbidextrous

Wound / Incision Status:

Orthosis/Splint Use:

Swelling:

Circumferential measurements (cms):

Right MCPs: cm

Left MCPs: cm

Right Wrist: cm

Left Wrist: cm

Right Left Digit AROM (extension is 0 unless otherwise indicated):

Thumb AROM:

IP: left: || right:

MP: left: || right:

Plan abd: left: || right:

Palm abd: left: || right:

Opp: left: || right:

Wrist AROM:

E: left: || right:

F: left: || right:

RD: left: || right:

UD: left: || right:

Forearm AROM:

Sup: left: || right:

Pron: left: || right:

Shoulder AROM:

WFL: left: || right:

Flexion: left: || right:

Extension: left: || right:

Abduction: left: || right:

IR: left: || right:

ER: left: || right:

Grip and Pinch Strength:

Sensation:

Palpation:

MODERATE COMPLEXITY OT CODE:

The patient's occupational profile and medical and therapy histories were reviewed through , and patient intake forms. An analysis was completed of the occupational profile/data based on a detailed assessment. The evaluation identified . Clinical decision making involved moderate analytic complexity and consideration of several treatment options. Minimal to moderate modification of tasks or assistance was provided. COVID19 precautions in effect.