Outpatient Occupational Therapy Evaluation Template

Outpatient Occupational Therapy Initial Assessment

Reason for Referral

Referred by Middlemore Hospital Orthopaedic Fracture Clinic on 14/05/2026 for outpatient OT rehab and functional retraining following ORIF of right distal radius fracture (sustained 02/04/2026). Cast removed 12/05/2026; presenting with decreased ROM, grip weakness, and functional limitations in ADLs and work tasks.

Occupational Profile

42yo RHD male (NHI: ZXC4829). Lives in a single-storey brick home in Manurewa, Auckland with wife and two school-aged children (8yo, 11yo). Primary breadwinner. Completed NCEA Level 2. Employed full-time as a warehouse storeman; currently off work receiving ACC weekly compensation. Regular analgesics: paracetamol 1,000 mg PO QID PRN.

Client Goals

• Return to full-time warehouse duties (lifting up to 15 kg) within 6 weeks.
• Regain independence in bilateral dressing Tasks (buttons, zippers) and meal preparation.
• Resume driving manual transmission vehicle safely.

Occupational Performance Issues

• ADLs: Difficulty with fasteners, cutting meat, and washing hair using RUL.
• IADLs: Unable to lift heavy pots, carry grocery bags > 2 kg with R hand, or perform lawn maintenance. Unable to operate manual gear shift safely.
• Work: Unable to perform heavy lifting, pallet wrapping, or operate forklift controls.

Cognitive and Psychosocial Function

Cognition intact; alert and oriented. Mild anxiety regarding financial impact of prolonged time off work and fear of re-injury during heavy lifting. Supportive family environment.

Physical Function and Functional Capacity

• R Wrist AROM: Flexion 30°, extension 25°, radial deviation 10°, ulnar deviation 15°, supination 45°, pronation 60°.
• Oedema: Mild dorsal wrist swelling. Well-healed volar scar, mildly adherent distally.
• Strength: R grip strength 8 kg via Jamar dynamometer (L grip 42 kg). Pinch strength: tripod 2.5 kg, lateral 3.5 kg.
• Fine Motor: Intact digit opposition to index/middle/ring; thumb to small finger lacks 1 cm. Decreased dexterity with small manipulation tasks.
• Pain: 2/10 at rest; 6/10 on end-range wrist extension and loading.

Assessment Tools Administered

• QuickDASH: 54.5/100.
• Canadian Occupational Performance Measure (COPM): Performance 3.5/10, Satisfaction 2.5/10.
• Jamar Dynamometer & Baseline Pinch Gauge.
• Structured observation of kitchen task (making a hot beverage): compensated with shoulder abduction and trunk lean during kettle pouring due to limited wrist extension and grip strength.

Environmental Context

Flat entry to home with 1 small step. Shower over bath with no grab rails (currently managing safely). Wife available to assist with heavy domestic chores and transport in the evenings; attends daytime clinic appointments via public bus (bus stop 200 m from home).

Summary of Assessment

42yo male presenting 6 weeks post-R distal radius ORIF with reduced R wrist AROM, significant grip weakness, and mild pain limiting bilateral ADLs, driving, and return to manual warehouse work. Good rehabilitation potential and high motivation.

Initial Plan / Recommendations

• Provide prefabricated volar wrist splint for high-risk/heavy activities; wean for light daily tasks.
• Commence Home Exercise Programme (HEP): scar massage 3x daily, active/active-assisted wrist ROM exercises, and tendon gliding.
• Issue adaptive equipment: built-up cutlery handles and non-slip Dycem mat for kitchen bench.
• Weekly outpatient OT sessions for progressive strengthening, work hardening, and functional task retraining.
• Liaise with ACC case manager regarding a graduated return-to-work (GRTW) programme on light duties in 2–3 weeks.

“Notes were prepared with assistance from an AI scribe. I confirm that the patient gave verbal consent. I have reviewed these notes and confirm that they accurately and completely document my clinical assessment.”