Reason for Services
Why is Harris receiving OT services?
He is recovering from an incomplete C4 spinal cord injury requiring total assistance with ADLs and mobility.
What degree is Harris working toward?
Bachelor’s degree in computer science.
Who is Harris’s primary live-in support?
His fiancée, Marsha.
What are Harris’s current movement capabilities?
Neck flexion, extension, rotation, and some shoulder elevation.
What is a short-term therapy goal for Harris?
Maintain skin integrity and prevent pressure injuries.
What was the cause of Harris’s spinal cord injury?
Motor vehicle accident.
What part-time job did Harris hold before his accident?
Bookkeeper for his brother’s plumbing business.
What physical barrier exists in Harris’s apartment building?
He lives on the 15th floor; elevators are available but apartment space is small.
What level of assistance does Harris require for transfers?
Total assistance with a mechanical lift.
What is a vocational goal for Harris?
Resume his bookkeeping work remotely using adapted computer access.
What additional orthopedic injury did Harris sustain?
Fractured left proximal radius and ulna, making him non-weight bearing on his LUE.
Name two leisure activities Harris enjoyed before his injury.
Golfing and traveling with his fiancée Marsha.
Name one environmental challenge at his brother’s home.
Six steps at the entrance without a ramp.
Why must Harris avoid using his left arm right now?
He is non-weight bearing due to fractures in the radius and ulna.
What long-term personal goal is Harris planning for?
Marrying Marsha after graduation.
Why is frequent repositioning necessary for Harris?
To prevent pressure sores due to limited mobility.
What weekly tradition did Harris and Marsha share?
Weekly movie date nights.
What strong social supports are present for Harris?
Marsha, his mother, brother, and regular family visits.
How might Harris’s routines change after his injury?
He will rely on assistive technology, caregiver support, and adapted routines for ADLs.
How can OT interventions support Harris’s independence at home?
Training in the use of assistive technology for communication and environmental control.
What specific movements will Harris eventually regain?
Neck flexion, extension, rotation, and shoulder elevation.
Why is Harris’s computer-based work important for rehab planning?
His job can be adapted for accessible technology, allowing continued work from home.
How does Marsha demonstrate her commitment to supporting Harris’s recovery?
She took time off work and wants to be involved in his care and therapy.
What is one major risk if Harris’s skin is not monitored closely?
Development of pressure ulcers.
What emotional priority is important for Harris's rehabilitation?
Maintaining hope, building emotional resilience, and re-engaging in meaningful life roles.