Occupational Therapy Discharge Summary

Client’s name: DM
Date of report: 04/13/2018
Date of initial referral: 01/11/2018
Primary intervention diagnoses/concern: Post CVA Nov 2015; RUE hemiplegia; expressive
aphasia, dysarthria
Secondary diagnosis/concern: Diabetes, Lupus
Precautions/contraindications: None
Reason for referral to OT: Work on building skill in RUE, manage tone, increase independence
in IADLs.
Student Therapist: Nikki Rietz, OT/S

S: Subjective Data

The client stated:

“I don't mind having my girlfriend put in my contacts for me, why do it when you can have

someone do it for you?”

“Everything I wanted to do, you did. I was over contacts, so you moved on.”

O: Objective Data

The client received skilled occupational therapy services for 60 minutes a week for 6 weeks in

the student outpatient clinic. The client was re-evaluated during the final therapy session and

the following assessments were performed: Canadian Occupational Performance Measure

(COPM), Box and Blocks Test, UE AROM measurements, and the AOTA Professional

Development Tool (PDT). The client was also provided resources upon discharge and

recommendations to continue use of HEP. The following information was gathered:

UE AROM Measurements in Degrees:

Active range of motion measurements were taken with the use of a goniometer in order to

measure changes in the client’s AROM in the client’s hemiplegic R UE.

Initial Measurements: Shoulder Flexion: 160; Shoulder Abduction: 85; Finger MP Flexion: 45

Final Measurements: Shoulder Flexion: 164; Shoulder Abduction 145; Finger MP Flexion: 45

Box and Blocks Test:

The Box and Blocks Test was administered to measure change in the client’s control of

voluntary movement and gross manual dexterity.

Hand Tested Number of blocks moved Number of blocks moved

T1- 01/25/2018 T2- 04/12/2018
Right 7 8
Left 38 45

The client independently initiated a tone reduction stretch during this assessment. When the

client’s tone increased, he utilized a raking grasp with digits 4-5 to manipulate blocks.

COPM:

The COPM was administered in order to measure change in the client’s performance and

satisfaction in the previously self-identified occupational problems.

OT Problem Importance: Performance: Satisfaction: Performance: Satisfaction:

Scored 1-10 Scored 1-10 Scored 1-10 Scored 1-10 Scored 1-10
T1- T1- T2- T2-
01/2502018 01/25/2018 04/12/2018 04/12/2018
Put in 9 1 1 1 1
contacts
Cutting food 4 4 1 6 6
Donning 4 4 1 5
socks and
shoes
bimanually
Typing on 3 2 1 3 5
laptop
Managing 2 5 1 3 2
and handling
money
Average 3.2 1 3.6 3.5
scores:
Change in .4 2.5
scores:

AOTA Professional Development Tool (PDT): Client Satisfaction Questionnaire:

The PDT questionnaire was given to the client to gather information on the client’s satisfaction

with occupational therapy services and his perception of improvement in therapy goals. The
survey results indicated the client was overall satisfied with the therapy program and is willing to

participate next year.

Therapy Goals

Long Term Goals Initial Performance Ending Performance

By discharge, client will
independently incorporate his
RUE to prepare a complex
meal.
The client did not incorporate
RUE when preparing a meal.
The client uses his RUE to
stabilize food, gather
supplies, and grasp food
objects and utensils when
preparing meals.

By discharge, client will
independently place contacts
in both eyes with use of one-
handed technique
The client did not know how
to place contacts in his eye
with use of one hand. The
client's girlfriend completed
this task for him.
The client has the knowledge
and skills to complete this
goal. The client understands
the use of the one-hand
technique but chooses to
have his girlfriend continue
helping him with his task.

A: Assessment

The client made great progress over the course of the 6-week treatment period. The client was

able to make significant improvements in functional AROM in R UE due to adherence to his

home exercise program, utilizing R UE in more function tasks, and use of PROM/AROM dowel

exercises performed in therapy. Although the client demonstrated minimal improvement in the

Box and Blocks test, he improved his lateral pinch and grasp/release skills when there are no

time constraints and he is able to incorporate more tone reduction breaks in between activities.

The client has demonstrated learning of compensatory strategies to manage and reduce tone

by independently initiating and implementing tone reduction stretches during functional

activities. As indicated by the COPM, the client’s overall satisfaction and performance in

identified problem areas had increased over the course of therapy services. The client was able

to successfully achieve his meal preparation goals due to: adherence to HEP, task specific

training, handling techniques, and implementation of tone management strategies. The client

was unable to achieve his goal of utilizing a one-handed technique to place and remove his eye
contacts due to lack of practice and change of priorities and interests. The client has the skills,

ability, and knowledge to complete this goal, if he so desires. As demonstrated on the PDT, the

client was satisfied with his progress made in therapy and the interventions offered. The client

also indicated that he appreciated the client-centered structure of occupational therapy services

and is excited to participate in the program next year.

P: Plan

It is recommended that the client be discharged from therapy services at this time. The client

has been instructed to continue with HEP to further enhance R UE active range of motion. The

client will benefit from continued task specific training therapy to improve motor control, and

community wellness programs for stroke and diabetes wellness and management. Programs

such as: The University of Utah’s Stroke Rehab Program and EPICC Diabetes Self-

Management Education Program were recommended as resources to the client upon

discharge. The client was also provided suggestions to create virtual reminders on his phone to

prompt the use of his RUE in everyday occupations. The client will continue to work on

grasp/release and fine motor skills at an outpatient clinic as well as continue his wellness

program at Sugarhouse Rehab Center to further enhance his occupational performance,

satisfaction, and quality of life.

Sign and Date:

Nikki Rietz, OT/S

04/13/2018