Occupational

Therapy Discharge Summary

Client: T.T. Date of Report: 4/13/2017
Age: 49 Date of Birth: 9/7/1967
Primary Diagnosis: Date of Initial Referral: 2/2/2017
Reason for Referral: Evaluation to increase independence and safety with ADL and
IADL tasks
Reason for Discontinuation: Completed 12 week student community client
program
Therapist: Abby Call and Shayna Roberts

S: The client stated, All of my therapy has helped me a lot.

O: The client was seen for skilled occupational therapy services 1x/week for 1 hour

in the Life Skills Clinic or in his home a total of 8 times as part of the community

client program. Services focused on improving trunk stability and balance,

incorporating his R UE into tasks, improving B UE motor control and coordination,

managing ataxia, and improving his insight and awareness for increased safety and

independence in ADLs and IADLs. Therapeutic interventions included neuro re-

education, ADL training, and therapeutic activities. The client was educated on

positioning for safety, body awareness, and signs of fatigue. The client explored

various leisure activities through therapeutic interventions and an activity checklist.

Overall, he is disinterested in leisure activities, but indicated some interest in being

outdoors, walks around the neighborhood, sports, music, books on tape, and social

media.

At discharge, the client demonstrates the ability to don and doff UB clothing, shoes,

and socks independently. He requires max A to fasten small buttons on a button up

shirt. He performs stand pivot transfers with min A for safety and positioning. He is

able to sit unsupported for 40 minutes with CGA. He requires mod verbal cueing for

posture and max verbal cueing to take breaks when he is fatigued.

Goal Initial Performance Ending Performance
Client will manage Client requires max A to Goal met 3/29/17
clothing during toileting manage clothing during
with CGA for safety toileting
Client will fasten pants in Client requires max A to Goal met 2/16/17
sitting with min A for fasten pants in sitting Independent 3/29/17
balance and coordination
Client will pull up pants Client requires max A to Goal met 3/23/17
with min A for balance stand and mod A to pull
pants over hips
Client will shower with Client is dependent for Goal discontinued per
min A for safety and showering clients request 3/29/17
thoroughness
Client will wash affected Client is dependent for Goal met 3/23/17
limbs with min A for washing affected limb
safety
Client will dry body with Client is dependent for Goal discontinued per
towel with min A for drying body clients request 3/29/17
safety and stability
A: The client has demonstrated progress in UB dressing (min A to I), LB dressing

(max A to min A), transfers (mod A to min A), sitting balance (max A to CGA),

postural endurance (15 min to 40 min), fine motor coordination and manipulation

(max A to I fastening pants), and use of his R UE (7 verbal cues to 1 verbal cue). He

continues to require cueing for posture, positioning, and fatigue awareness due to

poor body awareness, trunk strength, and trunk endurance. He requires extra time

and assistance with ADL tasks and transfers due to B UE ataxia, R hemiplegia, poor

motor control, and impaired balance and trunk stability. Areas of interest and

satisfaction he identifies are inconsistent, which may be due to language barrier,

poor insight, learned helplessness, and decreased volition. The information he

provides may or may not be accurate. B UE ataxia, R hemiplegia, poor motor control

and fine motor coordination, impaired balance and trunk stability, poor body

awareness, impaired insight, and diplopia continue to impact his occupational

participation, safety, and independence. He is being discharged from student

services due to the end of the community client program.

P: The client has met his goals and will be discharged from student services. He will

be referred to Heather Arias, OT, at the Life Skills Clinic for additional skilled

occupational therapy services to continue improving safety and expanding his

participation in meaningful activities. Vision therapy services are recommended. He

will continue receiving assistance from his home health aide 3 days/week. The

client requires new bed canes that can be safely attached to his bed.

Shayna Roberts 4/13/2017