OCCUPATIONAL THERAPY DISCHARGE SUMMARY

Date of Report: 03/05/2020 Client’s Name: J. K.

Date of Birth/Age: 52 Date of Initial Referral: 01/16/2020
Primary Intervention Diagnosis/Concern: Multiple Sclerosis
Secondary Intervention Diagnosis/Concern: Cognitive Decline
Precautions/Contraindications: Safety at home and in the community, cognitive decline, poor
judgement
Reason for Referral to Occupational Therapy: Concerns about him getting lost in the community
Reason for Discontinuation of Occupational Therapy: End of available sessions
Therapist: Brenda Banks, OT/S

Description of Intervention
J was seen 1x week for 8 weeks for occupational therapy at the Life Skills Clinic. Interventions addressed
his ability to stay safe while in the community, use phone apps to navigate in the community, and use
phone apps to communicate more effectively with family and friends. Interventions included exploration
of phone features and apps, repetitive learning about navigation apps, navigation skills while in the
community, activities to challenge his cognition, and overall safety. Interventions were based on
performance concerns identified by the initial assessments performed at the first two sessions and in week
five.

Progress Toward Goals

By week 5, J met his goal of being able to use Apple Maps to navigate in the community when he is lost
by demonstrating his ability to use the app with minimal verbal prompts during treatment sessions. He has
expressed the continued ability to use the app but has not expressed whether this has helped him while he
is out in the community. He has not met his goal of using cell phone features or apps to communicate
more effectively with family and friends, largely because he has expressed his lack of desire to use these
features. Chelsea assisted him with activating the text-to-speech feature on his phone, but it is unknown
as to whether he utilizes this feature or not.
Long-Term Goals
Within 6 weeks, J will be able to
independently use compensatory
strategies to navigate to his home
when he is lost in the community.
Within 6 weeks, J will be able to
demonstrate use of cell phone
features to improve communication
with family and friends with less
than 2 visual or verbal prompts.
Initial Performance
•Cannot use phone (Siri, Google
Maps) to navigate to his home
when lost in the community
•Family has tracking on his
phone to locate him when he is
lost (only when his battery is not
dead)
•He has poor vision and
therefore is not able to read
street signs in the community
•He has poor memory and
cannot recall where he is or
where he has been
•Has visual deficits which affect
his ability to read and send text
on phone
•Has a difficult time locating the
correct buttons/app to text on his
phone
•Does not have much desire to
learn about phone’s accessibility
features on cell phone
•Does not use any voice to text
features on his phone
Ending Performance
•J has shown emerging skills for using
navigation apps when lost in the
community
•Clients’ family has reported minimal
incidence of getting lost while in the
community during the past 8 weeks
•J’s visual deficits have not been
resolved. His mother states that she will
be purchasing another pair of glasses for
him to wear
•J has not shown any improvement in
memory or recall
•J’s visual deficits have not been
resolved. His mother states that she will
be purchasing another pair of glasses for
him to wear
•The text-to-speech feature was
activated on J’s phone and is available if
he chooses to use it
•J does not express a desire to use his
phone’s accessibility features (text-to-
speech) to communicate with family and
friends

Occupational Therapy Outcomes (OTPF)

The Canadian Occupational Performance Measure (COPM), the Contextual Memory Test- Part 1, the
Self-Reported Cognitive Dysfunction: Perceived Deficits Questionnaire (PDQ), Impact of Visual
Impairment Scale (IVIS), and a neurologic vision screen were administered during initial evaluation. The
Allen Cognitive Level Screen (ACLS) was performed on week 5 at the recommendation of our
supervisor, Pollie Price, Ph.D., OTR/L. All results were utilized to establish client-centered goals and a
plan for intervention. Client’s goals were focused on occupation- based goals related to cognition,
specifically attention and working memory. Throughout the course of treatment, goals were revised based
on client’s performance. The occupational therapy outcomes that were addressed include: improvement of
his occupation of being able to navigate throughout the community safely and without getting lost,
improvement of overall health and wellness and quality of life by enabling him to engage in social
activities and those occupations which bring him meaning, and providing education regarding the
prevention of factors that may potentially make his environment unsafe.

Discontinuation Recommendations/Resources
From the first meeting with J, he has expressed a desire to maintain his independence by continuing to
live alone in the community. There have been a few situations that J has mentioned during his sessions
that has cause for concern such as “wall crawling” or crawling on his hands and knees at home to get
around, frequent falls (at least monthly), not taking his medication on a regular basis, and admitting to
urinating in public when he is in the community and needs to go. Based on observations of J’s
 occupational performance, the aforementioned situations, and the results from the ACLS, it would be in
J’s best interest if he were to be in an environment where there are others who can assist him throughout
his day. After speaking with J’s mother, C ,about our concerns, she has expressed that this is something
that J and his family have been exploring but they have not found a solution. The following information
was provided to J and his family as resources that they may explore.

RESOURCE ABOUT CONTACT INFORMATION

Utah MS Society- Self- Self-help group for individuals living
Help Group with MS and their family members and
friends. Please contact Ashantai prior to
attending your first group meeting or for
more information.
https://www.nationalmssociety.org/Chapters/U
TU/Groups-and-Discussions/Programs/Salt-
Lake-City-Daytime-MS-Self-Help-Group
Ashantai (801)831-1270 or
ayungai@comcast.net

Meets 4th Thursday of the Month

11:00 AM MST - 12:00 PM MST
The Wentworth at Coventry
6895 S Whitmore Way
Salt Lake City, UT 84121
Salt Lake City MS Self-help group for individuals living https://www.nationalmssociety.org/Chapters/U
Society Support Group with MS and their family members and TU/Groups-and-Discussions/Programs/Salt-
friends. Please contact Kim prior to Lake-City-Self-Help-Support-Group
attending your first group meeting for Kim at kimcloward@aol.com
more information.

Meets Third Tuesday of the Month.

7:00 PM MST - 8:00 PM MST
Chapter Office
1440 Foothill Drive
Salt Lake City, UT 84108
Utah Independent Living The UILC is non-residential facility that https://uilc.org/en/
Center provides services which enhance the Todd Hansen: Intake Coordinator
independence of people with disabilities. (801) 466-5565
Five core services are:
o Peer Support

o Information & Referral

o Independent Living Skills

Training
o Advocacy

o Transition

ChairFit with Nancy Exercise for persons with Multiple https://www.youtube.com/

Sclerosis. Videos containing a wide
selection of exercises that can be done
from a chair. Includes elements of
Core, Cardio, Yoga, Tai Chi,
Zumba/Salsa (Latin inspired), strength
training (legs and arms), and stretching.
___________________________________________
Brenda Banks, OT/S Date