Reason for Services
Occupational History & Success
Contexts: Environment & Personal
Performance Skills & Patterns
Client Goals & Priorities
100

What is Harris’s current spinal cord injury level?

Incomplete C5 spinal cord injury.

100

What is Harris’s academic goal?

Complete his baccalaureate degree in computer science.

100

Where does Harris live?

In a one-bedroom apartment on the 15th floor with his fiancée Marsha.

100

What motor functions has Harris regained at this stage?

Neck movement (flexion, extension, rotation), shoulder elevation, and elbow flexion.

100

What is one of Harris’s short-term therapy goals?

Feed himself independently.

200

Why was Harris transferred to inpatient rehabilitation?

To focus on improving independence in self-care and mobility following acute stabilization.

200

What job does Harris have besides being a student?

Bookkeeper for his brother’s plumbing business.

200

What access challenge does Harris face in his brother’s home?

Six steps at the entrance and no ramp.

200

What motor functions are still impaired for Harris?

No active movement in his wrists or hands.

200

What upper body self-care tasks does Harris hope to regain?

Grooming and upper body dressing.

300

How long was Harris hospitalized before inpatient rehab?

10 days in an acute care hospital.

300

What leisure activities did Harris enjoy before his injury?

Golf, travel with Marsha, and movie nights.

300

How is Harris’s family supporting his recovery?

Daily visits, meals, emotional support, and Marsha taking time off work.

300

What level of assistance does Harris require for bed mobility?

Moderate assistance for pressure relief.

300

What longer-term goal outside of self-care is motivating Harris?

Returning to driving with adaptive controls.

400

What orthopedic injury complicates his rehabilitation plan?

Fractured left radius and ulna (non-weight bearing on LUE).

400

How did Harris's work flexibility potentially support his rehab?

His computer-based work can be adapted with assistive technology for accessibility.

400

Why is Harris’s living environment a potential future challenge?

Small space could limit accessibility for mobility devices and caregiving support.

400

What daily activities still require total assistance?

Transfers, toileting, and bathing.

400

How will OT interventions support Harris’s independence goals?

Training with universal cuffs, adaptive grooming tools, and positioning techniques.

500

Why is inpatient rehab important at this stage for Harris?

Intensive therapy now can maximize functional recovery in grooming, feeding, and dressing using compensatory strategies.

500

Why is Harris’s previous active lifestyle important to consider during therapy planning?

Reintegrating leisure activities supports emotional resilience and motivation in rehab.

500

How does Harris’s strong social support impact his rehab potential?

Increases emotional support, caregiving availability, and rehabilitation engagement.

500

How does elbow flexion recovery help Harris with functional goals?

Supports potential for self-feeding and partial grooming using adaptive devices.

500

Why is early focus on adapted independence critical for Harris’s psychological health?

Promotes hope, restores self-efficacy, and maintains a sense of personal achievement despite injury.

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