Occupational Therapy Discharge Summary

Date of report: April 16, 2021

Client name: BB
DOB: 53 y/o
Primary intervention diagnosis/concern: R-sided CVA in April of 2017 leading to L-
sided hemiparesis
Secondary intervention diagnosis/concern: Control of voluntary movement of the left
upper extremity.
Reason for referral to OT: Seeking additional services to address deficits due to R-
sided CVA
Reason for discharge from OT: Completed 8-week outpatient program
Therapist: John Barker (OTS)
S: Client stated that she was able to get on all 4’s (quadruped) this week for the first
time in a long time and said that therapy must be working
O: BB was seen for OT 1x/week for 8 weeks. Within therapy, the client participated in
education and practice in repetitive reaching tasks with focus on activating the triceps
and deltoids for elbow flexion and shoulder flexion/abduction. The client also learned
about the importance of using her L UE as much as possible to create new neural
pathways to increase L UE function. Additional strategies taught and used throughout
therapy included task analysis to incorporate L UE daily through a home program.
These strategies were implemented in activities involving productive IADLs such as
wiping a table, swiffering the floor, eating a bowl of cereal, boxing with punch mittens,
using an ironing board, feeding her dog, placing fruit in a bowl, putting away laundry,
turning off and on the faucet, inserting earrings, and closing her car door to lead to
occupational performance improvement. Interventions also addressed the client’s
knowledge about her condition and how to improve function, using one-handed
strategies to insert earrings, and closing her L car door using her LUE with use of A/E.
In place of a formal administration of the occupational profile, throughout therapy and
during the last session before discharge, client reported an overall increase in
performance in her L UE with increased movements at her shoulder and elbow as well
as satisfaction in identified occupational priorities compared to the start of therapy.
According to the client satisfaction questionnaire, the client is satisfied in the OT
services she received.
 
 Long-Term Goals Initial Performance Ending Performance

Independently close her L Closed her L car door with
car door with her L UE with use of her R hand 100% of
use of A/E the time. Could not use
and never used her L UE
to close her L car door.
Independently closes her L
car door with her L UE with
use of A/E. Uses her R
hand to position the A/E
and her L UE to close the
door. She no longer
reaches over with her R
hand to close her door

Independently insert post Required Min A to insert Can independently insert

earrings with back into her post earring with back into
left and right ears using her R ear and Mod A to
one-handed strategies  insert post earring with
back into her L ear with her
R hand.
post earrings with back
into her R and L ear with
her R hand. She is able to
insert R earring with one
attempt, it may take a few
attempts and a little time to
insert L earring.

A: Client reached STG 1a & 1b with use her L UE while activating her triceps for elbow
extension and shoulder flexors/abductors. She was able to reach LTG1 by inserting the
A/E into the door handle with her R hand, abducting her L arm and placing it through the
loop of the A/E and then adducting to pull the door completely closed. She was able to
reach LTG2 through one-handed techniques and compensatory strategies. She can
insert post earrings with backs in to both her L and R ears, but it may take a few
attempts to insert into her L ear due to the increased difficulty to manipulate objects with
her R arm targeting the contralateral L ear. Through practice, the attempts it takes her
and duration of time will decrease. An increase in movement in her L UE with her
shoulder flexors/abductors as well as with elbow extension was noted and
compensatory trunk movements have decreased to perform reaching tasks with her L
UE with occasional tactile and direct verbal cues. She reports an increase in use of her
L UE at home through tasks such as turning on and off the faucet and implementing the
home program. Client is motivated to continue to work hard to make additional progress
after discharge from therapy through the home program, continuing to receive therapy
elsewhere, and using task analysis strategies taught in clinic.
P: Client will engage in home program recommendations with the support from her
husband. She will continue to incorporate task analysis within her home and address
deficits of high tone and limited control of movement through use her L UE in
occupational tasks, SROM, and to perform repetitive reaching movements to further
increase L UE function. It is recommended that client continue to see OT and PT to
maintain and continue progress with L UE function and address L-sided hemiparesis.
 GAS chart
**HINTs: each column should have 3-5 bulleted measures.
***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline performance) and
then fill in the rest of the columns in between.
Distal Outcome (LTG): -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Level Better Much Better
(Occupation/Target Client will shut her Client will shut her car Client will Client will
Behavior) car door with her L door with her L UE independently shut independently shut
UE with Max A with with Min A with use of her car door with her car door with her
Driving/reaching and use of A/E A/E her L UE and the L UE
grasping car door to use of adaptive
shut, muscle power, equipment.
muscle endurance,
trunk stability

Proximal Outcomes (STGs) Measurement Baseline

Criteria
1) Client will independently reach and grab her steering Level of Assistance Client will reach to touch her steering wheel with Min A
wheel in the bottom left quadrant
2) Client will independently reach to touch her car door Level of Assistance Client will reach to touch her car door with her L UE using
when opened halfway with her L UE using A/E A/E with Min A

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.
Distal Outcome (LTG): -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Level Better Much Better

(Occupation/Target Client will insert post Client will insert post Client will Client will
Behavior) earrings with a back earrings with a back independently insert independently insert
Dressing, into her R ear with into her R ear post earrings with a post earrings with a
manipulating earring Min A and her L ear independently and her back into her left back into her left and
and back using one- with Mod A with use L ear with Min A with and right ears using right ear using one-
handed techniques, of one-handed use of one-handed one-handed handed strategies
fine motor skills, strategies strategies strategies with no more than 2
control of discrete attempts
voluntary movements

Proximal Outcomes (STGs) Measurement Criteria Baseline

1) Client will insert post earrings through each ear- Level of Assistance Client will be able to come from supine to sitting
piercing hold with Min A using her right hand with Mod A with the use of A/E
2) Client will independently put a back on post earring Level of Assistance Client will be able to come from a seated position
with the right hand, using one-handed strategies to standing with Mod A with use of A/E

Signature: John Barker (OTS)

Date: 4/16/2021