Case History Report Form,

Guidance and Consent Form

Client’s details ( * required)

*Name (first name)
*Chronological age (CA)
Actual age since birth
*Diagnosis and/or presenting problems
*Other products used
List other products used by the client as part of their 24-hour postural management programme. State where and how the products are used.
*Name
Address
Contact number
*Email
*Profession / qualification
*Number of years qualified
*Number of years experience with client group

Therapist / parent/ caregiver details ( * required)

*Product name
*Components or accessories used

Product details ( * required)

Assessment details –complete before using the product

Client’s weight
Client’s height or length in supine
Delete as appropriate
Developmental assessment, clinical observations, functional abilities
Include a description of the problem/need/weakness the person has. Append copies of assessment report / outcome sheets where appropriate.
Treatment strategy/goals for client
These should be very specific and measurable
Description of your planned intervention
State what your expected outcomesare for the client from using the product. List components to be used and why?
Describe why the use of the product is important to the client, family and/or clinicians.

ReviewAssessment

Record review results. Repeat initial assessment stages as appropriate, noting any improvements / deteriorations / new problems encountered / solutions. Note any changes to the configuration of the Leckey product, i.e. components added / removed. If possible, re-photograph your client.
Return to Clare Wright (Clinical Research Manager) at or by post after each review.

Client’s Details ( * required)

  1. *Client’s name (first name only)
  1. *Chronological age (CA): Actual age since birth
  1. *Diagnosis and/or presenting problems

4.*Other equipment used as part of 24-hour postural management programme (include where and how used)

Therapist’s / Parent / Caregiver Details ( * required)

  1. *Name
  1. Address, contact number and / or email address
  1. *Profession (if appropriate)
  1. *Number of years qualified and number of years experience with client group

Initial Assessment of Client (First Information Collection)

  1. Assess client using standardised developmental assessment; clinical observations; other measures (length, height, weight etc); functional abilities etc;
  1. Describe the problem/need/weakness the client has;
  1. Formulate objectives that the client can only accomplish when this problem/need/weakness is overcome. These should be very specific and measurable;
  1. Write a detailed description of your planned intervention and what your expected outcomes for the client are from using the Leckey product;
  1. Record components of the Leckey product you have selected to support your intervention programme. For example, with the Leckey Mygo, you should record:
  • Type of mobility base (e.g. powered, non-powered)
  • Type of chassis (e.g. hi-lo)
  • Trunk harness or chest harness
  • Foot sandals
  • Armrests
  • Tray and / or grab rails
  • Knee pad

Note the reasons why you have selected or omitted specific components;

  1. Digital photographs of client at initial assessment would be highly valuable (in and out of Leckey product);
  1. Record any subjective observations / comments / opinions from therapists / parents / guardians / other carers about the Leckey product in relation to:
  • Effectiveness – does the Leckey product support treatment / intervention as intended and why? (Or why not?)
  • Any specific benefits noted
  • Ease of use / adjustment
  • Aesthetic appeal
  • Any problems encountered.

Review Assessment(s) of Client (Subsequent Information Collections)

  1. Collect information at appropriate intervals. It is suggested that information should be collected between monthly and six monthly intervals to note change. This will vary with the problems and progress of each client, and the type of product being used.
  1. Record review results. Repeat initial assessment stages as appropriate, noting any improvements / deteriorations / new problems encountered / solutions. Note any changes to the configuration of the Leckey product, i.e. components added / removed. If possible, re-photograph your client.
  1. If your treatment objective from the initial assessment has been achieved, set a new objective and write this up as before.

When to Stop Collecting Information

Ideally information should be collected at intervals during the time the product remains suitable for the individual client. Long-term outcomes are more desirable, simply because they tend to be more reliable. However, if this is not possible, we think information from an initial assessment and three subsequent reviews (four pieces of information in total) will be sufficient. Obviously the time this takes will vary depending on your client’s age, level of ability, and the product being used.

The process is designed to provide you with evidence about the effectiveness of specific products in achieving clinical/functional objectives and overall goals with individual clients. Whether or not you choose another Leckey product, it is good practice to routinely record goals/objectives and outcomes.

When to Return Information to Us

Please return copies of your information (including photographs) to us after your initial assessment, and after each subsequent review. This way, we get to build up a picture as we go along.

It also means we have the information to refer to if you want help with writing up, or should you decide you prefer not to write up.

How to Return Information to Us

  1. By post:

Please return your information (including printed photographs) to us by post to the following address:

Clare Wright

Clinical Research Manager

James Leckey Design Ltd

19 Ballinderry Road

LISBURN

BT28 2SA

  1. By email:

Please return your information (including digital photographs) to us at the following email address:

Thank you.

I give consent for information about my child (including digital

photographs and videos) to be recorded by my child’s primary carer /

Occupational Therapist / Physiotherapist.

I understand this information will be used by James Leckey Design

to understand the effectiveness of their product(s).

I give consent for an edited and agreed (between myself / my therapist

/ Leckey) version of this information to be used by Leckey and their partners

(Otto Bock and Invacare) for marketing purposes, i.e. brochures, website.

I give consent for this information to be used as part of James Leckey

Design’s training and education programme i.e. presentations, workshop

handouts.

I understand that only my child’s first name will be used, although

my child may be recognised if photographs are used.

I understand that my child’s participation in the case study is voluntary

and I can change my mind at any stage without giving a reason. Changing

my mind will not affect the care my child or I receive.

I understand that all confidential information will be stored securely

as required by the Data Protection Act (1998).

______

Name of Parent/Guardian* DateSignature

______

Therapist Date Signature

*please delete

Please complete the form and return it to your Occupational Therapist or

Physiotherapist.

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