- client's demographic data - who is the client?
- client's occupational history - the past experiences.
- reason of the referral - why is the client seeking for the service?
- client's priorities - goal to be achieve from the treatment
(short and long term goal) - area of occupation affected - main current problem(s)
- context and environment - anything that support and inhibit occupational performance
Mr. Muhammad Akif, malay, 38
years old bus driver who works for 6 years for a public transport company. Mr
Akif was married and had 2 children, both still in primary school. He lived at rented
2 storey house with his family which 20 minutes commuting by motorcycle. His monthly
income was RM 1800++ and his wife didn’t work since they first child. Mr. Akif
never been promoted since working with his company because his unfinished SPM education. Mr. Akif works for 10 hours in a
working day and usually travel 2-5 hours before his break time. He started his
duty on 6.30a.m until 4.30p.m on morning shift and 1p.m until 11p.m on evening
shift. Mr. Akif was diagnosed with Symphysis pubis disruptions after motor vehicle
accident during his way back home. He suffered pubic bone displacement greater
than 2.5 cm, rupture of the anterior sacroiliac, the sacrospinous, and the
sacrotuberous ligaments, rendering his pelvis rotationally unstable. He was
referred to Occupational Therapy Department after 6 weeks wearing external fixation
to receive treatment;
ü
Compression therapy – edema treatment
ü
Active hip, knee and ankle movements
ü
ADL training
ü
Return to work training
ü
crutches, or walker as assistive devices
ü
partial weight bearing on the affected limb (not
earlier than 3 months post-operatively)
ü
The patients were followed up 6 weekly for the
first 6 months, every 3 months after that until a year and thereafter once a
year.
Mr. Akif was determining to return to works as soon as
possible after the surgery. He desires to be able to driven in less than 6
months. While using the crutches, he hopes the adaptation in his bus will
enable him to drive safely. On the first week of treatment with OT, therapist
found out Mr. Akif having problem in his:-
ü
ADL: functional mobility, bowel and bladder
management and personal hygiene and grooming.
ü
IADL: religious observance, community mobility.
ü
Works
ü
Leisure
ü
Social participation
As a working husband and father, Mr. Akif is unable to work
for his family and house payment due to his condition. In addition, his wife
had unemployed. However, his company is covered by insurance policy for
workers. He also is having trouble in transporting
in his 2 storey house. Especially, when he needs to go out of his house such as
going to the hospital. Mr. Akif’s wife was advised to move they bedroom to the
ground level for the temporary. Mr. Akif also having problem in full filling
his Friday prayers.
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This is only my version of occupational profile and haven't check by my lecturer yet. Thanks
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