SOAP discharge 3/8

S:

“Yeah, my hand is tight this week.”

O:

D.M. was seen this day in therapy in order to focus on evaluating improvement before

discharge and providing a home program. D.M. has been seen over the course of eight weeks

focusing on improving his wrist and finger extension along with radial and ulnar deviation. These

movements support the client's goals of using his right hand to open cans using a can opener

and maintaining a grip on a golf club throughout a swing.

Client’s long term goals were the following:

● LTG1: By d/c, Client will use his right hand to complete a simple cooking task with min

a of his left hand. *Goal met 3/8

o STG1a: Client, within 3 visits will open can utilizing his family can opener with

modI. *Goal met 2/1

o STG2b: In 3 visits, client will improve active extension of right-hand fingers to

reach and grip food items for cooking without the assistance of his left hand.

*Goal met 3/8

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
Much Less Less Expected Level Better Much Better
-Uses left hand as -Uses right hand -Uses right hand -Uses right hand -Uses right hand
Increase use of dominate hand as dominate hand as dominate hand as dominate hate as dominate hand
RUE during during cooking during cooking during cooking during cooking during cooking
cooking tasks tasks tasks for 30% of tasks for 50% of tasks for 75% of tasks for 100 % of
-Reaches for food the time the time the time the time
items with left -Reaches for food -Successfully -Successfully -Successfully
hand items with reaches for food reaches for food reaches for food
-Grips and extended fingers items with items with items with
transports food of right hand with extended fingers extended fingers extended fingers
items with left physical assist of of right hand on ⅗ of right hand on ⅘ of right hand on
hand attempts attempts 5/5 attempts
 -Does not use a left hand to extend -Grips and -Grips and -Grips and
can opener fingers transports food transports food transports food
-Grips and items with right items with right items with right
transports food hand with mod hand with min VC hand
items with both VC -Uses can opener -Uses can opener
hands and mod -Uses can opener independently independently
VC with modI
-Uses can opener
with modI
provided with
extra time

Proximal Outcomes (STGs) Measurement Criteria Baseline

1) Use can opener 1) uses adaptive equipment
2) right hand is able to grip and turn
knob
3) hand rotates for thumb to grab
underside of knob for next turn
1) does not participate in opening cans
2) right hand falls off can opener knob, does not
grip
3) does not rotate thumb down to grab knob for
next turn

2) Grip food items with 1)use of right hand 1) props with right hand
right hand 2)able to grip and move items
2) does not grip items

3) uses left hand to physically assist right hand

● LTG2: By d/c, client will independently swing a golf club using proper technique to hit a

ball. *

o STG2a: In 3 weeks, client will improve active right wrist extension by at least 5

degrees to independently swing a golf club.

o STG2b: STG 2b: In 3 weeks, client will improve right radial deviation by 10

degrees to independently swing a golf club.

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
Much Less Less Expected Level Better Much Better
-brings golf club -brings golf club brings golf club brings golf club brings golf club
Swinging golf half way back half way back half way back half way back half way back
club -right wrist is in 10 -right wrist is in 10 -right wrist is in -right wrist is in 25 -right wrist is in 30
degrees of degrees of 15-20 degrees of degrees of degrees of
extension extension extension (at top extension extension
-right wrist is not -right wrist is not of swing) -right wrist is in 15 -right wrist is in 20
radial deviated radial deviated -right wrist is in 10 degrees of radial degrees of radial
degrees of radial deviation deviation
 -makes contact -hits a tennis ball deviation (at top -hits golf ball -hits golf ball to
with a tennis ball to targeted of swing) towards targeted targeted location
location -hits the golf ball location
during swing
Proximal Outcomes (STGs) Measurement Criteria Baseline
3) Wrist Extension 1) type of swing (half) 1) half swing
2) degrees of extension
3) fluidity of motion 2) about 10

3)slow/irregular movement

4) Radial Deviation 1)degrees of deviation 1) none

2)fluidity of movement
2) N/A—no movement

During D.M.’s initial performance he utilized his right hand to grasp and twist can opener,

attempting to open a can while in a seated position. D.M. was unable to hold onto the handle of

the can opener, sliding off multiple times. When he was able to get his hand to hold and twist

forward, releasing his grasp, he was unable to bring thumb back under handle in order to

continue turning. D.M. hit the handle of the can opener with ulnar side of the hand in order to

twist knob to a sufficient degree where he could get a thumb in correct position under the knob.

D.M. was successful in opening a can, but it took a considerable amount of time.

During today’s session when D.M. was asked to open a can using a dycem covered

handled can opener. D.M. was able to turn the handle of the can opener enough to get a thumb

on the underside of the handle for next turn during, displaying no instances of using the ulnar

side of his hand. The can was opened in a timely manner.

During D.M.’s initial performance of golfing, he used his left hand in order to extend right

fingers and place golf club inside. He used his left arm to swing golf club, leaving his right hand

to slip off the club multiple times.

During today’s session, D.M. was able to extend his fingers of his right hand

independently to grasp the golf club, maintaining a grasp throughout a putting activity.

When D.M. was asked to re-rate his performance and satisfaction via the COPM, he

gave the following scores:

 Initial Assessment Scores Discharge Assessment
Occupation Scores

Satisfaction Performance Satisfaction Performance

1. Using right hand to open can 1 1 3 3

with can opener

2. Maintain grip on golf club 3 4 Putting: 4 Putting: 4

throughout swing Driving: 2 Driving: 2
*When D.M. was asked what his baseline score before his stroke for golfing he stated he would
have rated himself as a 6.

D.M.’s current active wrist extension and radial deviation were also measured:

Left extension: 70 degrees Right extension: 15 degrees

Left radial deviation: 14 degrees Right radial deviation: 5 degrees

After occupational observation, re-rating of the COPM and measurements of AROM, the

client was asked to fill out a client satisfaction questionnaire in order to provide student

practitioners with feedback. D.M. was overall somewhat satisfied with his achievements in his

occupational therapy program, although he did not experience any difference in managing

around his home and community.

D.M. also instructed on mirror therapy home program, given a mirror box and provided

with a list of community resources.

A:

Over the course of eight weeks, D.M. has made great strides in his ability to use his right

hand in meaningful occupations. This was seen by his increased ability to independently

incorporate his right hand into cooking tasks such as using a can opener and grasping to

transport food items. D.M. made minimal progress towards his ability to grasp and maintain his

grip on a golf club, due to tone and lack of motor control, impacting his ability to extend and
radially deviate his wrist. D.M.’s final AROM measurements were less than the original

measurements do to the initial measurements being taken after stretching and active use of

right hand, versus post measurements being taken at the beginning of therapy sessions before

any interventions. Therapy interventions towards his golf goal mainly focused on his ability to

use his right hand during putting activities instead of driving activities, impacting his final scores

on the COPM.

Through occupational therapy interventions D.M. was able to increase his participation in

his occupational activities and increase his sense of well-being. In the beginning of therapy,

D.M. oftentimes overlooked the capabilities of his right hand, using his left hand to compensate

for the lack of movement. Throughout therapy, D.M. was encouraged to use his right hand as

much as possible, being told the more he uses it, the more he would be able to gain from it.

D.M. was excited to implement home programs given over the eight weeks and was able to

incorporate his right hand into more activities than he had in the past, increasing his self

confidence and ability to use his right hand in a capable manner.

P:
D.M. was provided with a detailed handout and instructed on 6 mirror box therapy

exercise. D.M. was instructed to complete each exercise x10, BID, diligently for one month, and

then to self-evaluate. If the exercise have made a difference, to continue, and if they haven’t

then to stop the exercises. D.M. was also instructed to pick three daily occupations to always do

with his right hand, encouraging D.M. to create a habit of always implementing his right hand

whenever possible. D.M. selected to brush his teeth, comb his hair and turn door knobs with his

right hand.

D.M. was also provided with a list of community resources consisting of: Stroke Support

Group, Aphasia Talking Group, Free Meditation, Yoga for TBI and Post Stroke, Mastering

Meaningful Movement and Stroke Camp.

Therapist Signature _Shea Aldana, OTS Date __3/9/2019