Occupational Therapy Discharge Summary
Date of Report: April 13, 2018 Client’s Name: Community Client
Age: 57 Date of Initial Referral: January 25, 2018
Primary intervention diagnosis/concern: Brain aneurysm leading to brain bleed; LUE
hemiparesis
Secondary Diagnosis/Concern: Loss of grip strength, active ROM of the shoulder, mobility in
LUE
Precautions/contraindications: Allergic to iodine and scallops
Reason for referral to OT: Client has limited functional mobility impacting her performance
and participation in occupations including kitchen tasks and typing due to limited active ROM,
and loss of muscle control. Client is looking for adaptive strategies and therapeutic interventions
to increase function.
Therapist: Kayla Jensen (Burton), OTS
S: “I think today is a good day to try some of these visualization strategies.”
O: It is recommended that the client discontinue OT services based on the progress she has
made. Client was seen for skilled occupational therapy services for 7 weeks. Client participated
in bimanual kitchen and typing tasks that encouraged the use of her LUE and improved motor
control. Client demonstrated significant time in extending her fingers in her L hand to grasp
objects. Client also had limited functional mobility in her shoulder when reaching for items.
During the discharge session, the client participated in a visualization exercise which
incorporated swimming with both arms. Next, the client used both hands to type a positive
affirmation. She placed her L index finger on the spacebar and typed letters using her R hand.
Client and therapist reviewed the Brunnstrom Stages of Recovery as well as a home exercise
program. Lastly, the client walked her dog, while incorporating her L hand to hold the leash.
Long-Term Goals Initial Performance Ending Performance
LTG 1: In 6 weeks, client will use Client completed kitchen tasks Client uses her LUE as external
LUE 75% of opportunities during using her RUE only. Client and verbal indirect cues are
multi-step meal prep tasks demonstrated difficulty provided.
extending and isolating her
fingers, activating shoulder Client can fluidly extend her
flexion in her LUE to grab fingers in her L hand to grasp
necessary meal prep items, and meal prep items.
shoulder extension
Client has incorporated PROM
exercises throughout activities to
combat tone and increase
mobility
LTG 2: In 6 weeks, client will Client did not incorporate her Client’s typing speed increased
increase typing efficiency by LUE into typing. Client kept her by 5 wpm.
7wpm, incorporating LUE LUE to her side while she
pressed the keyboard keys with Client has implemented adaptive
her R hand. Client was slowed by strategies, using her L index
her need to press the spacebar finger to press the shift key and
and shift keys with her R hand as spacebar. Client also changed her
she used it to type the letters. environment by getting a
computer chair with arm rests to
Assessment Report: Client typed support her L elbow during
15-17 wpm. typing activities.
A: Client made good progress toward her goals. She met all her STGs and is progressing toward
her LTGs. Client has demonstrated improved coordinated movement of the LUE as seen by her
ability to open her hand and grasp objects of different sizes and incorporating shoulder flexion to
reach for items at varying heights. Client requires verbal indirect cues to use her LUE during
kitchen and typing tasks. Client tends to fixate on what she cannot do, inhibiting her performance
and engagement in completing tasks that requires the use of her LUE. Client becomes frustrated
when her L side is not performing as she wants it to. By using a visualization strategy, client has
shown a desire to participate in tasks without expecting the outcome to be perfect. Client has also
implemented compensatory strategies to improve her coordination and movement to complete
kitchen tasks while using her LUE. Client is taking the steps she needs to increase the use of her
LUE, as well as address how she perceives her current condition and function.
P: Recommendations for discharge include implementing a home exercise program which
encourages the use of the client’s LUE into everyday activities and completing PROM exercises
throughout the day as her tone increases. A support group for psychosocial care is also
recommended to address loss of function and resilience through the physical and cognitive
changes.
LTG 1: By discharge, client will use LUE 75% of opportunities during multi-step meal prep tasks
STG 1a: In 2 weeks, client will use LUE 25% of opportunities during multi-step meal prep tasks (Goal met
02/15/2018)
STG 1b: In 2 weeks, client will use LUE 50% of opportunities during multi-step meal prep tasks (Goal met
03/01/2018)
LTG 2: By discharge, client will increase typing speed by 7 words per minute, incorporating LUE
STG 2a: In 2 weeks, client will improve typing accuracy by 3 words per minute per assessment report
(Goal met 02/15/2018)
STG 2b: In 2 weeks, client will improve typing speed by 5 words per minute per assessment report (Goal
met 03/29/2018)
Kayla Jensen Date: April 13, 2018
