Example output · Occupational Therapist AI
What the Treatment Plan Builder actually produces
Takes a patient's diagnosis, functional limitations, goals, and treatment setting, then generates a structured occupational therapy treatment plan with an evidence-based intervention approach, measurable short- and long-term goals, and a session-by-session schedule with progressions.
- Patient Diagnosis:
- Right CVA with left hemiplegia, dx 6 weeks ago
- Functional Limitations:
- Impaired left UE motor control (2/5 strength), difficulty with ADL dressing and grooming, moderate balance deficits in sitting and standing, mild cognitive-perceptual deficits affecting task sequencing
- Patient Goals:
- Return to independent self-care, resume cooking simple meals, drive again if medically cleared
- Treatment Setting:
- Outpatient clinic, 2x/week
**Diagnosis & Precautions:** Right CVA with left hemiplegia, 6 weeks post-stroke. Monitor for fatigue, subluxation risk, and fall risk during all mobility transitions. Use armrest support and proper positioning. **Treatment Approach:** Occupation-based, progressive motor control and functional task training. Emphasis on active-assisted to active ROM for left UE and dynamic balance during ADL simulation. Use real-world tasks (dressing, meal prep, grooming) as primary interventions rather than isolated exercises.
**Long-term Goals (12 weeks):** 1) Demonstrate independence with upper-body dressing (shirt, buttons) with standby assist only. 2) Prepare simple one-handed meals (sandwich, cereal) with supervision and safety awareness. 3) Transfer sit-to-stand and ambulate with contact guard for household distances. **Short-term Goals (4 weeks):** 1) Improve left shoulder active ROM by 15° and demonstrate 3/5 grip strength. 2) Perform left UE grooming tasks (brushing teeth, washing face) with minimal assist. 3) Sit unsupported for 3+ minutes during tabletop activities. 4) Identify and verbalize one fall risk or environmental barrier in home/clinic.
**Frequency:** 2x/week, 60 min/session (outpatient clinic). **Weeks 1-4:** Progressive ROM work (active-assisted shoulder/elbow flexion-extension, 10-15 reps), functional grasp training with therapy putty and household items, seated dynamic balance activities (reaching games, weight shifts), upper-body dressing simulation with adaptive techniques (dressing stick, button hook trials). Introduce energy conservation education. **Weeks 5-8:** Advance to active ROM without assistance, functional meal prep tasks at clinic stove/counter, standing balance training near countertop, real dressing in clinic setting, introduction of adaptive equipment as needed (reacher, non-slip mat). Document adherence to home program. **Weeks 9-12:** Simulated cooking and ADL sequencing tasks, community re-entry preparation (if medically cleared), driving assessment planning coordination with provider, refine one-handed techniques, strengthen left UE endurance for 5+ min standing activity. Reassess ROM, strength, and functional independence measures. **Adaptive Equipment Recommendations:** Non-slip mat, one-handed cutting board, dressing stick, button hook, page turner (if needed). Trial items in session; recommend based on actual performance.
Replace the diagnosis, functional limitation ratings (e.g., MMT grades, balance level), patient-stated goals, and session frequency with your patient's actual profile. Review all goal language, precautions, and intervention recommendations against your clinical assessment before using in a chart or care plan.
Human review: All generated goals, precautions, and intervention recommendations must be verified by the treating occupational therapist against direct patient evaluation — this output does not substitute for clinical judgment or meet documentation standards on its own.
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