A detailed summary of a session(s) between an occupational therapist and a client where the aim is to produce a functional capacity assessment. This NovoNote template follows a layout which captures information considered appropriate to inform a functional capacity assessment report. The domains of functional capacity in this template are aligned with Australian National Disability Insurance Scheme (NDIS) guidelines.
Functional Capacity Assessment
Client Name:
Date of Birth:
Date of Assessment:
Time of Assessment:
Location of Assessment:
Name of Clinician:
Other People Present:
Referral source/reason for referral
Description of who referred the client and the purpose for the assessment.
Presentation during assessment
Client’s presentation and participation during assessment, including mental status, cooperation, enthusiasm, understanding, cognitive functioning, and communication abilities.
Diagnoses and medical history
Client’s diagnoses and medical history, with summary of impact on functional capacity and everyday life.
Current medications
Current medications including names, doses, frequency, conditions treated, side effects, adherence, and effectiveness.
Background
Client’s background including developmental, education/employment, social, family, trauma, medical, and substance use history. Summary of how diagnoses and difficulties have affected life.
Client goals
Client’s goals including NDIS goals where applicable.
Family, social, and formal support
Family, friends, social relationships, living arrangements, formal supports, day programs, and client’s evaluation of support quality and quantity.
Home environment
Current home environment, living arrangements, advantages and challenges, impact on disability, and detailed physical environment information.
Domains of functional capacity (including ADLs)
Assistive technology and environmental modifications
Current assistive equipment and technology in use, clinician recommendations for new aids or modifications.
Outcome measures and assessment tools used
Names and detailed results of outcome measures and assessment tools used, including psychometric measures and their relevance to client’s disability.
Client strengths, skills, and hobbies
Client’s strengths, skills, interests, hobbies, recreational activities, positive personality traits, and unique positive aspects.
Summary of findings
Key barriers to participation, overall capacity across domains, summary interpretation of functional capacity.
Risks and safety concerns
Risk factors including self-harm, physical health, social risks, protective factors, and action plans for known risks.
Recommendations
Clinician recommendations for supports, services, therapies, NDIS-aligned recommendations including assistive technology, support hours, accommodation, transport, community participation, and rationale for recommendations. Future appointment details.
Functional Capacity Assessment
Client Name: Mary Blogs
Date of Birth: 15/06/1995
Date of Assessment: 15/03/2024
Time of Assessment: 10:00 am
Location of Assessment: Client’s home
Name of Clinician: Sarah Smith, Occupational Therapist
Other People Present: Jennifer Blogs (mother)
Referral source/reason for referral
Mary was referred by her GP for functional capacity assessment following diagnosis of autism spectrum disorder to determine support needs for NDIS application and community participation goals.
Presentation during assessment
Mary presented as cooperative and engaged throughout the assessment. She demonstrated good comprehension and provided detailed responses to questions. Mary exhibited some anxiety when discussing social situations but remained focused on assessment tasks.
Diagnoses and medical history
Mary has been diagnosed with autism spectrum disorder and generalised anxiety disorder. These conditions significantly impact her ability to engage in social situations, maintain employment, and participate in community activities independently.
Background
Mary completed Year 12 and attempted university studies but withdrew due to social anxiety and difficulty with course demands. She has limited employment history with brief casual positions ending due to workplace social challenges. Mary lives with her parents and has minimal social contacts outside family.
Family, social, and formal support
Mary lives with supportive parents who assist with daily planning and social situations. She has one close friend from school but struggles to maintain broader social connections. Mary currently receives no formal disability supports but expresses interest in accessing community programs.
Home environment
Mary lives in a two-storey family home with her own bedroom upstairs. The home environment is supportive and structured, though Mary reports feeling isolated when spending extended periods in her room.
Domains of functional capacity (including ADLs)
Client strengths, skills, and hobbies
Mary demonstrates strong artistic abilities and enjoys painting and drawing. She shows excellent attention to detail and has strong academic abilities in areas of interest. Mary is empathetic and caring towards family members.
Summary of findings
Mary’s autism spectrum disorder and anxiety significantly impact her social participation and independent living skills. She requires moderate support for community engagement and employment preparation, with particular focus on social skills development and anxiety management.
Risks and safety concerns
Mary experiences episodes of social withdrawal and anxiety that may impact her mental health. Protective factors include strong family support and willingness to engage with appropriate services.
Recommendations
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