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Occupational Therapy Discharge Summary

The client made good progress in occupational therapy, meeting two of his long term goals of independently participating in preferred activities at home and completing simple meal preparation with minimal assistance. While he did not meet his goal of completing ADLs with minimal cues for his left side, he made improvements in actively using his left arm more and requiring less cuing. He was discharged with a home program to continue the strategies learned in therapy to further improve his independence.

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431 views4 pages

Occupational Therapy Discharge Summary

The client made good progress in occupational therapy, meeting two of his long term goals of independently participating in preferred activities at home and completing simple meal preparation with minimal assistance. While he did not meet his goal of completing ADLs with minimal cues for his left side, he made improvements in actively using his left arm more and requiring less cuing. He was discharged with a home program to continue the strategies learned in therapy to further improve his independence.

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Occupational Therapy Discharge Summary

Background Information
Date of report: 3/6/2020 Client’s Name: S
Client date of birth: x/x/xxxx Date of referral: 1/16/2020
Primary Diagnosis: Right CVA
Precautions: Left Homonymous Hemianopsia, Left inattention, Impulsive
Reason for referral to OT: lack of independence due to left hemiparesis, left inattention, and left visual-
field deficits.
Reason for discharge: reached number of approved visits and reached majority of goals.
Therapist: Benjamin Robison, OTS

S: “I will keep trying to use my left arm. I know that if I work at it, I will get better. When I support my

arm my shoulder doesn’t hurt as much.”

O: The client was seen once a week for an hour for 8 weeks to increase his occupational participation

and satisfaction. The client initially participated in a modified COPM and identified using his left arm in

ADLs as a main priority as well as lessening caregiver burden on his wife. His reported satisfaction and

performance was low (‘around a 2’). The client completed intervention designed to teach techniques

for scanning to address left inattention (lighthouse technique), encourage active use of left arm in

functional tasks, instruct on the benefits of weight-bearing to increase neural connections and decrease

shoulder pain due to subluxation, instruct on ROM exercises to prevent immobility, and to provide

strategies for safety management. Post-intervention COPM results were around “8 or 9” for satisfaction

and performance in increased use of left arm during ADLs and in being able to do more, thus decreasing

caregiver burden. He and his wife also reported a decrease in the amount of cuing she needed to

provide to counter his left inattention. The client completed a post-therapy survey and indicated that he

was somewhat satisfied with his achievements from therapy, stating that he “could have done more” to
make intervention more successful. He indicated a greater ability to manage occupations around his

home and the community, a greater amount of independence, and a high level of satisfaction with his

therapy program. The client indicated that therapy targeted activities that followed his interests and

goals.

Long-Term Goals Short-Term Goals Initial Performance Ending Performance


By discharge, Client STG: Client will Client completed Client completed
will complete ADLs independently activities requiring activities using strategies
with minimal v/c to complete personal maximum direct verbal to incorporate his left
attend to L side of grooming, cues to attend to his left UE. Client independently
body. Goal not met. incorporating L UE side. Client did not use developed strategies for
through the use of left UE during activities. using his L UE. Client
compensatory Client was impulsive and completed activities
strategies. Goal met started activities without requiring moderate
3/5/2020 care for safety. direct verbal cues to
STG: Client will attend to his left side.
complete shower Client displayed
routine with occasional impulsiveness
minimal direct v/c to when tired or losing
attend to L side. concentration.
Goal not met.
By discharge, Client STG: Client will Client did not engage in Client completed simple-
will independently complete simple preferred activities meal preparation using
initiate participation in meal preparation related to simple-meal strategies for safety,
two preferred using adaptive preparation and donning scanning techniques for
activities when at techniques and min preferred clothing. left inattention, and
home as per physical assistance. techniques to
personal/wife report. Goal met 3/5/2020 incorporate left UE.
Goal met 3/5/2020 STG: Client will Client donned preferred
complete dressing Levis using suspenders
with preferred and self-designed
clothing and techniques to
minimal physical manipulate clothing.
assistance. Goal met
3/5/2020

A: The client has made good progress and has met LTG 2 and associated STGs. He continues to actively

use his L UE more than he did at baseline and requires less cuing. This increased use of his left UE has

increased his occupational participation, increased his role competence in household tasks, and has

increased his quality of life and well-being. His wife also reports greater satisfaction in caregiving and in
the client’s performance. The client also reports supporting his L UE more than he did at baseline, which

will prevent future shoulder pain and joint damage while also lessening demands on his right side. He

still requires moderate cuing to attend to the L side and so did not meet LTG 1, associated with minimal

cuing for L inattention. Skilled services could still make improvement with his L inattention. His wife will

need to continue to provide support in this area and was encouraged to provide indirect verbal cues to

encourage the client’s ability to think of this need independently. The client expressed awareness that

he needed to be aware of his environment due to inattention to the left side and his propensity to be a

fall risk. This shows improvement of safety awareness and ability to assess environmental risk.

Continued impulsiveness and fall risk determine that the client should not be alone in environments

where he could hurt himself falling (walking on concrete) and where inattention could cause harm (using

a hot stove). The client’s wife will continue to need to provide assistance and support to ensure safety.

The client and his wife were instructed about balancing providing assistance and allowing the client to

do as much as possible to encourage growth. The wife expressed that she would allow him to do as

much as he could whenever possible. The client was prepared for discharge by being instructed on

incorporating all elements of care into daily activities: scanning strategies, active use of L UE, using ROM

exercises in everyday movements, and using weight bearing on L side. He expressed motivation to

continue making progress. The client was discharged with a home program, encouragement to engage

in support groups, and information for reaching out in case he had questions.

P: The client was discharged from OT services and sent home with a program to continue treatment

strategies of scanning to the left, incorporating the L arm into activities, using weight bearing, and

practicing ROM exercises. The client is well prepared for discharge and expresses motivation to

continue work.
Signature: Benjamin Robison, OTS Date: 3/6/2020

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