OTIE Adult Psych Worksheet 2

Client is cooperative and responds appropriately to questions.

• Subjective Findings (Contexts)

• History of Present Illness

• Occupational Profile

• Demographic Data

• Mental Status Exam

Client reports living in a rented apartment with her mother and two siblings.

• Subjective Findings (Contexts)

• History of Present Illness

• Demographic Data

• Occupational Profile

• Performance Patterns

Client identifies lack of motivation and trouble sleeping as main concerns.

• Occupational Profile

• Performance Patterns

• Demographic Data

• Subjective Findings (Contexts)

• History of Present Illness

Observed to have slouched posture and minimal eye contact during interview.

• Demographic Data

• Occupational Profile

• Subjective Findings (Contexts)

• History of Present Illness

• Mental Status Exam

Participates in daily grooming with moderate assistance from caregiver.

• Objective Findings (Occupations)

• Demographic Data

• History of Present Illness

• Subjective Findings (Contexts)

• Occupational Profile

The client is a 32-year-old female referred by psychiatrist for evaluation.

• Demographic Data

• Occupational Profile

• History of Present Illness

• Subjective Findings (Contexts)

• Performance Patterns

Difficulty planning and organizing tasks was noted during group activity.

• Performance Skills

• Demographic Data

• Occupational Profile

• Subjective Findings (Contexts)

• History of Present Illness

Client is currently taking Risperidone 2mg twice daily.

• Demographic Data

• Occupational Profile

• History of Present Illness

• Subjective Findings (Contexts)

• Performance Patterns

There was a significant incident at work where the client lashed out at a co-worker.

• Subjective Findings (Contexts)

• Occupational Profile

• Demographic Data

• History of Present Illness

• Performance Patterns

Client participates in family meals as a part of her evening routine.

• Performance Patterns

• Occupational Profile

• Demographic Data

• History of Present Illness

• Subjective Findings (Contexts)