OCCUPATIONAL THERAPY DISCHARGE SUMMARY

Client’s name: Client (TP)

Date of referral: 1/25/18

Date of report: 4/16/18

Age: 52

Primary intervention diagnosis/concern: Right sided CVA, Left sided hemiparesis

Secondary diagnosis/concern: Depression

Precautions/contraindications: N/A

Reason for referral to OT: Right sided CVA and improving occupational performance with left

sided hemiparesis

Reason for discharge from OT: Completed student led occupational therapy 8 week program

Therapist: Jessica Brauzer, OTS, Meghan Berry, OTS

S: “My hand is already pretty fatigued from dealing the cards”- our client’s response when asked

to incorporate her L hand during a card game of Rummy.

O: Our client participated in a student therapist led occupational therapy program for 1 hour per

week, for 8 weeks. Our client was seen to address improving engagement of LUE, and

improvement of fine and gross motor control of her LUE. During the initial session with our

client, we observed and retrieved information from a semi-structured interview (Canadian

Occupational Performance Measure); and learned that our client was not incorporating her LUE

into everyday activities, secondary to learned non-use. After collaborating with our client, we

decided on goals that would focus on functionally incorporating her LUE into ADL and IADL

tasks: 1) incorporating LUE when dressing with fasteners and 2) incorporating LUE for home
management tasks such as laundry and washing dishes. The student therapist and I decided to use

task specific training to improve the motor control in our client’s LUE. During our initial

sessions, our client used her LUE 50% of the time for dishes, laundry, and simple meal prep

activities, without direct verbal cueing. We educated our client on ways to move her LUE out of

its flexor synergy pattern, and to adjust her compensatory postures. As our client continued to

consistently come to our therapy sessions, she received constant verbal cues, strategies, and

learned how to control her movements through task specific training in dressing (fastening) and

home management tasks (cleaning, laundry, dishes, simple meal prep), thus helping to transfer to

her occupations outside of the clinic. During the middle of the program, our client was given a

home exercise program (HEP), which included mirror therapy exercises and reminders to

functionally incorporate her LUE (through a calendar reminder sheet). Toward the end of the

program, our client met her dressing goal, and was beaming brightly when she walked into the

building and showed us that she could now incorporate her LUE for fastening upper body

garments. Our client partially met her home management task goal, as she mainly uses her right

dominant hand to complete those tasks. During her last session, our client completed a “client

satisfaction questionnaire” and found the therapy sessions to be helpful, satisfying, and we

worked on the goals that she wanted to address moving forward.

Long-Term Goals Initial Performance Ending Performance

Our client will independently Due to learned non-use and After task specific training

fasten an upper body garment her LUE moving in a flexor and incorporating strategies

using compensatory synergy pattern, our client learned from student

strategies. was not incorporating her therapist, our client was able

LUE into dressing activities to independently fasten upper

 requiring fastening body garments (zipping up

(buttons/zipper), and required her jacket).

physical assistance.

Our client will independently Due to learned non-use and After task specific training,

incorporate her LUE 100% in mainly moving her LUE in a and the facilitation of normal

dishes and laundry tasks. flexor synergy pattern, our movements with quality and

client was not incorporating efficiency, our client is

her LUE into home functionally incorporating her

management tasks (cleaning, LUE into BUE required tasks

laundry, dishes). She 90% of the time with 1-2

incorporated it 50% of the direct verbal cues.

time and required 5 direct

verbal cues.

A: Our client made good progress during the 8 week OT program. While she achieved her

dressing goal, she is quite close to meeting her laundry and dishes goal. By incorporating her

LUE in functional tasks, this will help to continually strengthen the neuromotor connection

between her brain and motor movements. Through learned strategies, constant verbal cues, and

task-specific training in therapy, our client will transfer what she has learned and continue to

improve the efficiency and quality of her LUE movements. This will occur by slowing down her

movements to allow her to have better control over the tasks that she completes every day. Our

client was overall satisfied with the progress she made in the 8 weeks.
P: It is recommended that our client continue to adhere to her HEP 2x/day for 5 min/day, which

includes mirror therapy exercises and reminders to functionally incorporate her LUE, in order to

improve her occupational performance and quality of life. It is also recommended that she join a

recreation center in her hometown to get involved with a low impact exercise such as water

aerobics, to address social participation and health and wellness. It is likely our client will

continue to receive OT services next year (2019) at the University of Utah College of Health

building.

Therapist: Date:

Goals:

LTG1: By discharge, client will independently fasten an upper body garment using

compensatory strategies. [GOAL MET 3/29/18]

STG1: By discharge, client will incorporate LUE when manipulating fasteners in dressing

routine with no more than 2 verbal cues. [GOAL MET 3/29/18]

STG2: By discharge, client will demonstrate UE bimanual motor control to fasten fasteners for

dressing with no more than 1 verbal cue. [GOAL MET 3/29/18]

LTG2: By discharge, client will independently incorporate LUE 100% in dishes and laundry

tasks.

STG1: By discharge, client will incorporate LUE 85% of time when putting dishes away into

cupboard with no more than 2 verbal cues.

STG2: By discharge, client will fold 10 pieces of laundry utilizing LUE 90% of time with no

more than 1 verbal cue. [GOAL MET 3/29/18]