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Occupational Therapy Case Summary

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Occupational Therapy Case Summary
Regarding Occupational Therapy - 6 sessions; CA MTUS Chronic Pain Medical Treatment Guidelines support an initial course of physical therapy with objective functional deficits and functional goals. The latest progress report noted that the patient has left upper extremity pain. The exam revealed moderate spasticity and tenderness over the flexor-extensor forearm. She has a positive compression of the left median and radial nerves of the extensor and flexor forearms. It was noted that she has not received medications or occupational therapy. The guidelines support an initial trial of 6 sessions of PT. Additional requests should include objective functional improvement. Recommend certification.

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