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Discharge Summary

The occupational therapy discharge summary describes an 8-week therapy program for a client who had an MCA stroke. Through once weekly sessions, the client was trained to use adaptive equipment and compensatory strategies to increase use of her left upper extremity and improve occupational performance in dressing, grooming, and cooking. The client met her short-term goals of using compensatory strategies and adaptive equipment with her left arm and experienced improved occupational performance and satisfaction. While further progress is needed to fully meet long-term goals, the client gained skills to practice at home to continue therapy.

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106 views4 pages

Discharge Summary

The occupational therapy discharge summary describes an 8-week therapy program for a client who had an MCA stroke. Through once weekly sessions, the client was trained to use adaptive equipment and compensatory strategies to increase use of her left upper extremity and improve occupational performance in dressing, grooming, and cooking. The client met her short-term goals of using compensatory strategies and adaptive equipment with her left arm and experienced improved occupational performance and satisfaction. While further progress is needed to fully meet long-term goals, the client gained skills to practice at home to continue therapy.

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api-517961977
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Occupational Therapy Discharge Summary

Date of report: 03/05/2020 Client’s Name: Client

Primary intervention diagnosis/concern: S/P R MCA Stroke

Reason for referral to OT: Increase occupational performance and participation in ADLs and IADLs.

Therapist: Vanessa Russell, OTS

S: In response to how Client felt about therapy, she stated “I feel like therapy was helpful”.

O: Client was seen for OTS services once weekly for 8 weeks. She was trained on the use of AE and
compensatory strategies in order to increase the use of her LUE, and there by enhance her occupational
performance in dressing, grooming and cooking tasks. AE training included using utensils and grooming
tools with built up handles, jar openers for meal preparation, and zipper extenders on when dressing.
Compensatory strategy training included activity planning to identify when and how to use AE with LUE,
and to identify methods to remind her to attend to and use her LUE throughout the task. Client
completed final COPM, as noted below, and satisfaction of therapy questionnaire.

COPM

OP Problem Imp. Performance T1 Performance T2 Satisfaction T1 Satisfaction T2


1. Fastener/dressing 7 3 10 2 10
2. Grooming 6 7 10 4 10
3. Cooking 6 8 10 10 10
TOTAL 19 18 30 16 30
Average 6.3 6 10 5.3 10
Score changes 4 4.7

Goals

Long Term Goals Short Term Goals Initial Ending Performance


Performance
1. In 6 weeks, client a. In 2 weeks, client will use Uses RUE only for Uses compensatory
will use LUE after 1 compensatory strategies with ADL’s/IADL’s strategies to use LUE with
verbal prompt or less 2 verbal prompts to use LUE less than 2 verbal prompts
to assist with ADL’s for dressing with fasteners. when dressing with
b. In 4 weeks, client will use
and IADL’s. fasteners. Independently
LUE after 1 verbal prompt to
uses LUE to assist RUE
assist RUE with retrieving
items for cooking. when retrieving items for
cooking.
2. In 6 weeks, client a. In 4 weeks, client will Does not use Independently uses AE
will independently independently use AE with adaptive equipment with LUE to cut foods of
use adaptive LUE to cut foods of various for ADLs/IADLs various textures.
equipment in LUE to textures for meal
complete preparation and eating.
ADLs/IADLs. 
A: Client has met all her short-term goals and has made progress towards meeting her long-term goals.
Performance skills met in her short-term goals cannot be generalized to her long-term goals, as not all
ADLs and IADLs were addressed in therapy. She has improved her occupational performance with the
use of her LUE in completing dressing, grooming, and cooking tasks by using AE and compensatory
strategies. The overall outcome measures met in therapy, as suggested by Client’s response to the
satisfaction questionnaire and her attainment of goals, were improved occupational performance and
participation, leading to enhanced quality of life.

P: Client will practice intentional use of LUE with AE in ADLs and IADLs by analyzing task demands,
planning how to execute the task, and then implementing her plan while at home. She will perform self-
ROM exercises before and after tasks to prevent LUE from fatigue and tightening. She has been provided
with resources for AE and community resources for adaptive recreation, support groups, and exercise
programs.

Vanessa Russell, OTS

March 5, 2020

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