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Dap Notes

Client #1 made progress from moderate assistance to modified independence in lower extremity dressing. While motivated, she lacks confidence in ambulation and is unsure about returning home. Therapy will continue until goals are met. Client #2 fatigued during therapy but is progressing towards goals of functional ambulation and independence. She will continue therapy until discharge next week. Client #3's standing time improved but she has low pain tolerance, hindering progress. Goals of independence require adaptive equipment for home. She will complete inpatient therapy this week and continue outpatient care if needed.

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Dap Notes

Client #1 made progress from moderate assistance to modified independence in lower extremity dressing. While motivated, she lacks confidence in ambulation and is unsure about returning home. Therapy will continue until goals are met. Client #2 fatigued during therapy but is progressing towards goals of functional ambulation and independence. She will continue therapy until discharge next week. Client #3's standing time improved but she has low pain tolerance, hindering progress. Goals of independence require adaptive equipment for home. She will complete inpatient therapy this week and continue outpatient care if needed.

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Client #1 DAP Note:

97535- Self-Care/ 2 Units/ 30 Minutes

97110- Therapeutic Exercise/ 2 Units/ 30 Minutes

D: Client participated in 60 minute skilled Occupational Therapy treatment session. Clients goal related to this
treatment included modified independence with AE while dressing and during morning/night routine. Client
previously wore TED Hose in order to control swelling but did not require further use of them at this time. Client
mentioned, “I am going so fast without those stockings!” Client focused on client factors of Mental functions of
sequencing complex movements, memory, and experience of self and time. Performance factors addressed within
this session included: Reaches, grips, manipulates, flows, and handles. Client reported pain on Likert scale of 2
during therapy session. Further reported that pain medication is taken in order to manage consistent pain. Client
needed full 30 minutes to complete morning routine which included dressing, toileting, and hygiene. Client stated,
“You should bring the wheelchair to therapy.” Client is min. assist during transfers and ambulation. She is
motivated to return home but, “doubts that it will happen” however, is motivated to work during therapy.

A: Client has progressed from moderate assistance in LE dressing to modified independence with use of AE. It
appeared that client is unsure of ambulation and feels unsafe while ambulating. Her lack of confidence in her
ability indicates that she is not completely ready to return home where she would feel safe. Client has no further
indications that would limit her from achieving goals related to modified independence in dressing. Because client
is motivated, therapy will continue to progress to goals until discharge.

P: Client will continue will skilled Occupational Therapy for 6x/week at 60 minutes per session until client has met
goals and is modified independent in dressing. No further recommendations.

Client #2 DAP Note:

97110- Therapeutic Exercise/ 2 Units/ 30 Minutes

D: Client participated in 30 minute session of skilled Occupational Therapy treatment. Goals of this client include
functional ambulation, independence in ADL’s, strengthening and standing for longer than 10 minutes which will
be achieved before returning to assisted living in which services are provided. Client factors focused on in session
included: Memory, Muscle power and Muscle endurance. Performance skills further included: Endures, Reaches,
Moves, Walks and Paces. Client fatigued after 5 minutes of ambulation toward therapy gym but stated, “My
therapy is all in the afternoon and I am worn out.” After taking a short break, client was able to perform task to
increase strength and endurance. Client is modified independent in ambulation with the use of a 4-wheeled
walker. She is independent in all ADL’s but has questionable cognition. Client normally remains quiet during
treatment and reported no pain during session. Client has recently fallen in which she landed on R UE. R UE is
reported to be sore. During treatment using UE, Client will use left hand only.

A: Client is progressing towards goals. Client has previously ambulated for more than 5 minutes however, fatigued
today which is believed to do with previous therapy and lack of a break between therapy treatments. Due to
clients weakness and poor memory, client’s fall resulted in soreness in the R UE. Client will continue towards goals
and appears motivated in therapy to reach goals.

P: Client will continue with Skilled Occupational Therapy at 6x/week until discharge on Tuesday at 30 minutes per
session. Client will return to Assistive living where meals and other services are provided.

Client #3 DAP Note:

97530- Therapeutic Activity/ 4 units/ 60 Minutes


D: Client participated in skilled Occupational Therapy treatment for a duration of 60 minutes to focus on her goals
of increased standing time while performing a functional activity and promotion of independence throughout
occupations. Client stated, “I cannot do this. My knee hurts too bad. I don’t like this. No, I’m not doing that.”
However, once therapy was in progress such statements ceased to be made. Client was able to stand for 9 minutes
in order to complete task. When standing still or sitting for more than 3 minutes, her knees became stiff and
bothersome due to low pain tolerance. She stated, “Oh Ouch! My knees.” At this point in therapy she would begin
to tear up when she would initiate movement. Once movement was initiated, pt. stated no pain. Therapy session
focused on occupations of IADL’s and Leisure with client factors including: emotional, muscle power and
endurance. Performance skills that were worked on in therapy session included: reaches, stabilizes, paces, moves,
endures and navigates. No standardized assessments were performed.

A: Clients ability to stand for an extended period of time is improving. Progress has increased from no standing at
initial Occupational Therapy intervention to standing 9 minutes with the assistance of a walker, wall or counter.
Pt’s pain tolerance hinders her from achieving to her fullest ability during therapeutic sessions. Goals of becoming
independent are still in progress as client fatigues when standing for less than 10 minutes, thus making extended
functional activity difficult. In order to return home, client will need adaptive equipment of shower grab bars and a
four wheeled walker.

P: Pt. will continue skilled Occupational Therapy until the end of the week (x2 sessions at 60 minutes per session)
when facility is planning to discharge. Client will be set up with grab bars and walker per therapy’s request. Client
will then continue with outpatient therapy if needed.

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