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Discharge Summary (25 Points) (Sames, 2014; p.199) (due 4/21; 4/23)
_ _ (2) Summarize description of intervention
_ _ (5) Progress toward Goals summarized objectively
_ _ (5) Occupational Therapy Outcomes (OTPF)
Initial perfonnance in areas of occupation
Current level of perfonnance in areas of occupation
_ _ _ (5) COPM given, and accurately interpreted and displayed
~--(2) Client Satisfaction Evaluation was given (AOTA-PDT)
-b. (3) Contextual Aspects related to discontinuation and recommendations
_ _ (3) Discontinuation recommendations
_ _ __.professionally written; -1 point for every error in grammar, spelling, punctuation and organization
96od ~
_1.... Final Reflection (5 points) (due 4/23): How did your intervention plan tum out? Did your client surprise you in any way? Would you
change anything? If you were to continue to see this client, what would you suggest would be the next steps? Are there areas of being a
professional that you will target during FW 11?

~i .ic:
~
&-W-6!) C'.)5 ~ - fnfs ~ 92. ~ .
~ How did your intervention plan turn out? Did your client surprise you in any way? Would you
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change anything? If you were to continue to see this client, what would you suggeSt would be the

next steps? Are there any areas of being a professional that you wish to target during FWII?

The intervention plans turned out well with the client as far as her willingness to try them. She

was willing to try any activity that we came up with during the session and wanted to participate.

Though she was willing to do any activity we planned, she wasn't always able to complete the
. .. 1 t>u, 1'.u.tu.a- t o ~-(_J..w.._~
act1v1t1es that we planned or complete them in the way that we expected. Often her tone was too

high for her to do the movements, or sometimes the client wanted to stick to her own way of

doing things. I think that if I could have changed anything about the treatments I would have
o'J<-.
focused more on cognition and her balance. During our sessions it started to become apparent

that she was compensating for forgetting information and this really became evident to us about

halfway through our treatments. The client forgot scheduled therapy sessions and would repeat

things that she had told us previously. I think that ifwe were to continue to see this client there

would be more intervention focused on her cognition, specifically targeting memory. I would

also work on implementing ways for her to work on balance safely. Some of this was hard to

implement because the client missed so many sessions from the beginning of ~ arch to the

second week of April. It was bard to have consistency with our client because of all the sessions

that she missed and the lack of follow through at home. During FWII I think that I would like to

target more areas related to splinting and modalities. We did not have opportunities to implement
~~ . '
modalities with our client so working on them in fieldwork could be very beneficial. I also think

that this client was so high functioning in a lot of her tasks and had already adapted that it was

hard to implement new ways of completing tasks.

 Date of report: April I Jm. 2018 Date of referral: January 20 J 8 Clients name: Laurie

Primary intervention/concern: R side basal ganglia CVA, decreased function in left UE due to

a Botox injectfon and CVA .

Reason for referral to OT: Continuation of skilled OT treatment to supplement for only being

able to go two times a month to current OT.

Reason for discharge: Completion of semester for student therapists.

Therapists: Jen M and Lindsey W

S: " I am not sure I will do Stroke camp; I think it would be hard with my setbacks."

O: The client was seen at the occupational therapy clinic by students for ~none-hour sessions,

with one hour a week for treatment as a result of a right side CVA. The client sought treatment to

focus on fine motor control and residual impacts on her LUE after a Botox injection. She is also

working with an OT a couple of times a month at the University of Utah Sugar House Health

Clinic. The client was observed to actively participate in therapy services with the students

throughout treatment. During the final session, the client completed a kitchen task related to
?

organizing cabinets and drawers. The client stated she was fun sized so she was unable to reach a

lot of the items in the cabinet. As a result, the task was graded down to include the silverware

drawer that the client could reach. The client was able to utilize her left hand to grip items in the

drawer and also used her right hand to support her left hand when moving items that were

heavier or larger. The client is limited in her supination of her wrist when carrying items, as

demonstrated by her carrying items with her wrist pronated and flexed with sharper items like

the knives pointing towards her. The client required min verbal cues to complete the task with

direction of where items should be placed, and was able to independently move items in the

drawers. The client also organized the dishes that were washed and put them away in cabinets,
 demonstrating that she remembered where items went from the first session. The client was able

to place the items in the cabinets without assistance but required task rearrangement by moving
the items to be near the drawer all at one time to complete the silverware task safely. The client

was also administered the AOTA Professional Development Tool during this session. The client

stated that she was overall very satisfied with therapy and felt that it was an excellent

opportunity. She stated that she was thankful to have been able to work with the student

therapists. The client was very thankful and pleased with the time she has spent in occupational

therapy with the students. She was thankful that the students had taken the time to work with her

and spent time doing what she asked during treatment. The client was very happy and supportive

of the students and said she would be continuing occupational therapy treatment and homework.

'LTG Initial Final

LTG 1: By April 13th, 2018, The client was unable to On March 2nd, the client was

the client will complete complete desired household able to make her bed in 12

desired household tasks by tasks in under 30 minutes at minutes, demonstrating that

decreasing the amount of the start of therapy, especially she had met her goal.
--
-
time to less than 15 minutes related to making her bed.

The client was unable to pick The client demonstrated

- ·
LTG #2: By April 13 th, 2018 up items off the ground progress in this goal, but she

the client will pick up an item without momentary LOB or would benefit from continued

off the floor with LUE, propping with her right hand focus on balance as well as

without stabilizing or LOB. when bending to grab adaptation of the tasks

something off the ground requiring her to get items off

with her L hand. the floor.

I
 A : The client completed the session with the students and was able to actively engage and

remember where items were located in the cabinets and drawers. She showed skills in memory

and her retrieval of information that was learned in previous sessions. She demonstrated progress

in adapting the task to best fit her needs and her safety by being willing to change how she

completed the task. The client was able to organize the silverware drawer due to her ability to

reach and not to stabilize or stand on her toes, as was required for the cabinets. In this :final

session the client did continue to demonstrate deficits related to SUJJinating her arm and

completing tasks related to extension of her fingers. When completing preferred occupations

related to organizing the silverware and cabinets, her Jack of ability to supinate her wrist was due

to the high tone in her LUE. This was also noticeable when completing the task of moving

knives into the drawers, as she kept the knife pointed towards her body and her wrist was flexed.

P: The client has benefited from previous OT and PT in the past, as well as Stroke camp and

would continue to benefit from consistent therapy, and attending Stroke camp again. It is

recommended that the client continues these services, focusing on improvement in the use of her

LUE and balance. At discharge it is recommended that the client continues her preferred

activities at home to help improve the supination of her LUE and to continue with her current

level of functioning to increase occupational performance. (:tn')-tzy-} l,l..V- ~lYUZ> ,._. ~ ?

The goals and progress are listed below:

Goals:

L TG 1: By April 13 th • 2018, the client will complete desired household tasks by decreasing the

amount of time to less than 15 minutes. Goal Met 3/2/18

d-
 th
Sl'G: By April 13 , 2018 the client will make her bed with her fitted sheet in less than 6 minutes.
J>er client rePort. - Goal Met 312118 r

STG : By April 13•h. 2018 the client will independently utilize both her left and right UE in a
vacuuming task. Goal Met 312/18 +-

L TG #2: By April l3u,. 2018 the client will pick up an item off the floor with LUE, without

Stabilizing or LOB. - The goal has not been met and the client would benefit from continued

focus on this goal. She was able to pick up an item off the floor but stabilized herself with
her right arm. !-

STG: By April 13•h, 2018 the client will demonstrate increased L hand finger extension by
releasing grip of various objects.

The client reached this goal on 4/13/18 -1-

th
STG: By April 13 , 2018 the client wilJ independently demonstrate the use of her LUE in a

cleaning task without momentary propping of her R UE.

The client is continuing to work on this goal. I:-

Therapist: Jen Messer MOT Student

April 14 th, 2018

4/IL// I<(

,
 AOTA Professional Development Tool (PDT)

Client Satisfaction I

CLIENT SATISFACTION QUESTIONNAIRE

Cl ient: Lauri f' Date: Lj j I7> I \'6

Please c ircle the number corresponding to your response for ea ch question.

1. Do you remember your goals in occupational therapy?

f'f'fwes
lf}No
2. How satisfied are you now with your achievements in your occupational therapy
program?

[1] Not very much

[2] Somewhat
@'e,ymuch

3 . Have your achievements in your occupational therapy program helped you manage your
I
daily living activities?

Not very much

@ Somewhat
Very much

4. With the achievements you have made in occupational therapy, you have experienced
(choose one):

[ 1] More difficulty managing around your home and in your community

[2] No difference in managing around your home and community
~ Less difficulty in managing around your home and in your community .i

5. With the achievements you have made in occupational therapy, you are:

[ 1J More dependent on others

[2] No difference in depending on others
[3 J Less dependent on others

6. How satisfied are you with the occupational therapy program?

[1] Not very much

_J,JJiomewhat
~erymucb

Copyright AOTA, Inc. 2003. All Rights Reserved. 1

 AOT A Professional Development Tool (PDT)

7. Were the activities you worked on in occupational therapy those that you were intereSted
in learning?

(I] No
(2] Partially
~Yes

8. Did you wish instead to work on other activities in occupational therapy?

(1] Yes
).;lPartially
~ No

9. Did you feel that the therapist had some understanding of what your day would be like
for you after you no longer had therapy?

(I] No
)ltfartially
'c...8}'Yes

If you answered no, what more did you think that the occupational therapist should have
known about you? Describe:

Additional Comments:

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~~ ~ ltMK- 0ft ~ (Ah Le fo
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L ~ S' 0
vi.~0,--,_---_
Adapted with pennission from Dunn, W., Brown, C., McClain, L., & Westman, K. ( 1994). The
ecology of human performance: A contextual perspective on human occupational. In Royeen,
C. D. (Ed.), The Practice ofthe future: Putting occupation back into theory (AOTA Self-Study
Series Lessons 1-11). Bethesda, MD: American Occupational Therapy Association.

Copyright AOTA, Inc. 2003. All Rights Reserved. 2