Occupational Therapy Case Study Report

This assignment presents a detailed case study of an individual undergoing occupational therapy. The report focuses on the patient's journey from hospital to a café, highlighting their motor skills, process skills, social interaction abilities, and overall adaptation to their environment. It analyzes the effectiveness of the therapy through specific examples and observations, emphasizing the patient's reported satisfaction and improved capacity for performing activities independently.

Occupational Therapy Report
Date of report:
Name of person: Craig
Date of birth: Age:
Initial concern: Concern has been expressed over the physical disability of Craig that has
rendered him psychologically disoriented. He suffered from a lack of morale and a traumatic
depression that he would never be able to return to the mainstream life. Therefore, Craig’s
GP reported referred to an Occupational Therapy for him, after seeking consent from his
family.
Background information: According to the background data collected, it was understood
that the Craig was suffering from a severe mental trauma and depression, ever since his
accident. He became a quiet person, spending most of his time alone and had lost his
interest in the daily activities. He felt like a paralyzed man, who would have to depend on
his family for the rest of his life. He stooped meeting people and would spent time locked
his room. It took an impact on his psychological orientation as well as on his general well-
being. No amount of counseling or group support therapy would motivate him. He was
unable to perform an activity on his own and was in constant need of a support. He viewed
himself as a burden of the family and the society who had been cut off from the mainstream
life. At this point, his family, together with his GP decided that an Occupational Therapy was
necessary for the patient to help him adjust to his new life so that he could help improve his
performance and self-reliance as an individual.
Focus for occupational therapy assessment: The focus for the Occupational Therapy is to
get a drink for himself by going out of the hospital building to the café. In accomplishing this
task, the patient would not take anybody’s effort.
Findings from observation:
Overall quality of performance:
The patient was able to accomplish the task without any difficulty. In carrying out his task,
he did not pose any danger to himself or to anyone. Manifested a moderate physical
activity. The subject had exercised his independent judgment and willpower in
accomplishing the task, as he got himself a drink from the café independently. He had
accomplished his task within a moderate amount of time. He posed no personal or
environmental risk and was socially appropriate.
Client’s satisfaction with his performance: Craig was highly satisfied with his performance
as he had achieved his target of wheeling out of the hospital and getting himself a drink
without anybody’s support. The patient has manifested an increased confidence level and
was happy with the improvement of his effort.

Client’s Key Stakeholders satisfaction with his performance:
The key stakeholder of the Client is his wife, though she was not available at the time of the
interview. She is reported to help him with everything like take his shower. According to the
patient, in his wife’s view, he is just a lazy man and not an invalid man.
Environment and task objects:
The patient was in a hospital setting and is physically challenged. Therefore, he had to rely
on wheelchair and the same. The hospital ambiance was calm and sympathetic and involves
the exercising of discipline. The physical platform where the action was carried out was at a
café that had a comparatively high noise level and visually a bright space, peopled with
customers. The task object required him to go out of the hospital building and get himself a
drink from the café. Acquiring the drink by himself meant an achievement for the patient.
Skills which most impacted performance:
Social interaction skills
The patient had started the work with no problem and concluded the same without any
problem. He is capable of speaking and gesticulation as he went to the counter and bought
the drink for himself. The only problem that was observed was after the purchase of the
drink bottle, he had to the support the bottle with his mouth as he was endeavored to
wheel his chair around. He has no problem in replying or reciprocating in terms of
communication. The time duration elapsed in the process of communication is normal and
exhibits verbal acknowledgment. In fact, the patient has exhibited accommodation in terms
of adapting to social interaction.
Process skills:
Paces, Attends and Heeds
The patient had no problem in sustaining his performance as he had correctly understood
the task that was allocated to him and had carried out the same through his exercise of
judgment (Fisher, 2014).
Applying Knowledge
Upon understanding the task that was assigned to him, the patient had employed his
reasoning, inquired and handled the task without any problem.
Temporal organization:
In terms of the temporal organization, the patient had no problem and has manifested
individual confidence. He had successfully, initiated, sequenced and continues and
terminated the task given (Taylor, 2017).

Adapting to the performance:
The patient had adjusted accommodated with little or no problem with the performance
environment. Consequently, he has benefited from the task as he gained his self-confidence
and has successfully adjusted with the social environment.
Motor skills:
Body position
The patient seemed to have mild problem in initially stabilizing and aligning his body
position when he had purchased the drink bottle and was trying to make his way to the
table. Otherwise, he had no problem in his body positioning
Obtaining and holding objects:
The patient had successfully manipulated and co-ordinated his grip of the drink bottle. He
holds it in his mouth to adjust the position of his wheelchair.
Moving self and object:
The patient successfully transports himself to the café on his wheelchair and hold the drink
bottle in his mouth for momentary spout to adjust his body.
Sustaining Performance:
He has sustained his performance through endurance and willpower.
Adaptation skills:
It has been observed that the individual had adjusted to the surrounding environment
through the application of the social interaction skills. It involved the application of the
process skills and model skills. He was able to integrate his approached with those of the
surrounding environment as he had successfully accomplished the therapy assessment.
Conclusion / Summary of report
It could be, therefore, gathered from the report that the occupational therapy exercised on
the patient had been successful. The patient was able to implement his motor and process
skills in accomplishing the assessment. As he independently, wheeled out of hospital to the
café and achieved bought himself a drink shows his improved capacity to perform his own
activity. The client has reported satisfaction as he was able to exercise his willpower and
judgment in accomplishing the goal. The therapy had helped in adapting to the mainstream
social interaction by overcoming his physical challenges.
References

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