Module 2 - Developing a Client Profile: Getting the Big Picture

Referral information may include:

• Minimal client data set required from your medical record system
• Diagnosis and current health status
• Funding source and details
• Social and care arrangements
• Reasons for referral
• Referrer details
• Details of the current seating and mobility system, including product name and sizes
• Photographs - see handy tips for taking a photo of the client in a wheelchair
• Previously trialled or used system and the outcomes.

Other useful information to assist the planning of the initial assessment:

• Planned medical interventions
• Transfer skills
• Transport requirements
• Self-care status and equipment: toileting, eating, drinking, showering and dressing
• Communication and judgement skills
• Precautions and contra-indications (eg, autonomic dysreflexia, seizures, MRSA in wound).

Referral information is useful for:

• Screening for eligibility or prioritisation of the requested service
• Planning for the initial assessment:
  • Deciding whether a community referral or home visit is required to assess the environment prior to seating intervention, e.g 
    • A client who currently uses a manual wheelchair and has requested a power wheelchair. The environment and community access should be assessed by a community-based occupational therapist first
    • A client performs functional tasks in a specific environment based on the current wheeled mobility dimensions or specifications, for example, sliding transfer on/off bed or toilet, accessing a modified kitchen, computer set up at home
    • A client who has gained weight and requires a much wider wheelchair which may impede access around the home
  • Deciding if other team members' input and pre-assessment consultation are required, e.g
    • Consultation with a wound nurse specialist to assess pressure wounds
    • Consultation with a spinal physiotherapist to assess shoulder joint and transfer technique
    • Consultation with a medical practitioner regarding medical management, for example, pain and spasm issues
    • Consultation with a dietician regarding client's significant weight gain
  • Deciding what other reports, tools and trial equipment you may need for initial clinic assessment, trials and intervention