Discharge Note

Background Information
Date of report: 3-6-2020 Clients Name: L
Primary intervention diagnosis/concern: Multiple strokes in both L and R hemispheres. L
hemiparesis. R visual field cut. Cognitive impairments
Precautions/contraindications: left ankle instability
Reason for referral to OT: Left hemiparesis and cognitive impairments interfering
Reason for discharge from OT: End of allotted sessions. Continued therapy services at
sugarhouse outpatient.
Therapist: Miranda Anderson, OTS. Amber Darlington, OTS

S: Caregivers and L thanked therapists several times for all of the therapeutic efforts.

O: L was seen for OT 1x/wk for 8 weeks. L participated in practicing new techniques and using
adaptive equipment for dressing and bed mobility. Techniques used focused on increased use
of her left side, utilizing adaptive equipment, and increasing independence.
L’s long term goals are listed below:
Long-Term Goals Initial Performance Ending Performance
By discharge, client Maximum assistance Client requires
will pull up using grab was needed from moderate assistance
bars from supine to caregivers to move to move from supine
sitting EOB with min from supine to sitting to sitting EOB. There
assistance EOB. were sessions when
the client required
only minimal
assistance but this
performance was not
consistent.
LTG: By discharge, Moderate assistance Client requires
client will don a was need to don a minimal assistance to
pullover shirt while large pullover short Don a slim fitted
seated with min sleeve shirt while pullover shirt sitting
assistance. seated EOB.

L and L’s mom completed the Canadian Occupational Performance Measure (COPM), which is
an assessment that identifies top priorities for goals and outcomes as well as the perception of
the current performance, and performance over time in each specified area. The following
items were indicated as highest areas of concern that were addressed in therapy:

Occupational importance Initial Initial Discharge Discharge

Performance performance satisfaction performance satisfaction
 Priorities
Sitting EOB 10 5 3 9 9
and assisting
more for
daily
dressing.
L and her caregivers completed a client satisfaction survey to determine their satisfaction with
therapy services.
Client Satisfaction survey results:

L and caregivers were given a home program with step-by-step written and visual instructions
for upper body dressing while in a seated position as well as suggestions for greater
independence with transfers and bed mobility. Options for home-made as well as store bought
bed ladders were presented as new piece of adaptive equipment that L has shown improved
bed mobility with.
A: L made good progress. She was able to achieve 1 long term goal for dressing and was still
making good progress bed mobility. Her Sitting EOB goal was not met because her performance
from week to week was inconsistent. Clients parents were originally using dressing techniques
and bed mobility taught at initial discharge from the hospital when the client’s active
movement and skills were not as improved as they are now. Techniques used did not focus on
L’s participation and independence. L has demonstrated the ability to learn new strategies to
improve performance in both dressing and bed mobility. Meeting her goals has shown a large
increase in L’s participation and independence. In addition, she also has shown an increase in
satisfaction with her performance as seen in the COPM discharge scores. L’s strengths have
been addressed with caregivers to increase their understanding of how her strengths and skills
can be used to increase independence. L and her caregivers are taking steps to learn new
techniques and skills to further enhance L’s participation and independence.

P: L will continue with occupational therapy and physical therapy services in the sugarhouse
outpatient clinic. They will continue practicing techniques given in the home program as L
works towards greater independence.

Signature:
Date: 3/6/2020