Occupational Therapy Discharge Summary

Background Information

Date of report: April 13, 2018 Date of initial referral: January 24, 2018

Client’s name: XXX Date of birth/age: XXX

Primary intervention diagnosis/concern: Right Cerebral Vascular Accident (CVA) in the basal

ganglia as a result of antiphospholipid antibody syndrome (APS)

Secondary diagnoses/concerns: Complications to left upper extremity (LUE) as a result of a

phenol alcohol injection that was used in an attempt to help relieve LUE spasticity/tone.

Reason for referral to OT: To improve LUE hand function

Reason for discontinuation of OT: End of OT student community client experience

Therapist: Lindsey Ward

Subjective (S): “I am very lucky to have had this experience with you both, I was the person that

got the last spot in stroke camp last year and the last spot in this OT student treatment. I am so

lucky to have Jeanette here to encourage me and provide me with these opportunities.”

Objective (O): The client was seen at the University of Utah student outpatient therapy clinic

1x/wk for 6 sessions and discharge. The client’s initial performance and ending performance

related to her long-term and short-term goals are documented below in the following table:

Goals Initial Performance Ending Performance

By April 13, 2018, the client
will make the bed with clean
sheets and comforter in less
than 30 minutes, per client
report.
Goal Met 02/16/18
From our understanding the
client was taking 30 minutes
to put on only the fitted sheet.
During our fourth session, the
client mentioned that it is
now taking her 16 minutes to
make her bed. This led us to
ask exactly what she meant
by this and she clarified that
it was the fitted sheet, a sheet,

New LTG: By April 13,
2018, the client will complete
household tasks while
bending at the waist with no
loss of balance.
STG1: By February 23, 2018,
the client will produce slight
finger extension in order to
remove the left hand from
under the mattress after
fitting the sheet, per client
report.
Goal Met 02/16/18
New STG1: By March 16,
2018, the client will safely
vacuum the house while
holding the cord with the left
hand.
as well as her comforter
within this time frame.
Therefore, the
accomplishment of this goal
was more of an initial
misinterpretation of what the
client had communicated.
The client would occasionally The client continues to
experience loss of balance demonstrate LOB as she
when completing household focuses on a UE task while
tasks. moving. The client
demonstrates a greater risk
for LOB when stepping
backwards as opposed to
forward.
The client was unable to During our fourth session, the
produce active finger client mentioned that she was
extension to remove her L able to complete our LTG;
hand from under the mattress. therefore, the LTG and STG
The client used her R hand to were discontinued. This STG
assist in extending her L was discontinued as finger
fingers to remove the grasp extension is involved in the
on the sheet and then she meal preparation goals
would pull out the L hand. presented below.
The client experienced a LOB The client continues to
while transitioning from the demonstrate a LOB when her
tile floor to the carpet. She L UE and LE are involved in
was able to catch her balance. the task of vacuuming. She
has determined that it is safer
to pay someone to come in
once a week to clean.

STG2: By March 30, 2018,
the client will bend down to
grab one sheet form the
laundry basket on the floor
with her left hand, with no
loss of balance.
By April 13, 2018, the client
will use her left hand for
more than 50% of the
The client required
significantly more time to
obtain an item from the floor
with her L hand as compared
to her right. Additionally, the
client held onto the table
tightly with her right hand
while bending and reaching
to the ground with her left
hand.
The client used a lateral key
pinch with her left hand to
gather the ingredients, to hold
the measuring cup while
The client continues to
require significantly more
time to obtain an item from
the floor with her L hand. The
client continues to perform a
wide base of support and
support from the environment
to obtain items.
The client continues to use a
lateral key pinch for
obtaining most items. The
client is able to perform L
 unilateral tasks performed
during meal preparation.
Goal Met 04/13/18
STG1: By February 23, 2018,
the client will be able to
break 50% of the ice out of
the ice tray with left wrist
rotation.
STG2: By March 30, 2018,
the client will open the fridge
with the left hand and release
grasp from handle by
producing 50% of complete
finger extension.
measuring the ingredients, thumb abduction to release
and dumping the ingredients lateral key pinch. The client
into the bowl. continues to require active
The client used the R hand to assist from her R hand to
hold the L hand onto the position items in her left hand
spoon as she stirred the prior to use of the object. The
ingredients together and to client is able to perform
scoop and put the muffin mix approximately 60% of
into the muffin pan. unilateral tasks with the L
Overall, the client used her hand.
left hand for approximately
40% of the unilateral tasks
during meal preparation.
Client was unable to produce Discontinued 03/02/18
ulnar and radial deviation to The goal was discontinued
twist ice cube tray. because the client has an ice
maker in her home; therefore,
this goal was no longer a
priority for therapy.
The client was unable to As the client grasps the fridge
produce any active finger or the oven, she still requires
extension of the L hand. After assistance from her R hand to
completing full flexion of the pry her fingers from the
L hand, she required active handle on 3/5 attempts. The
assist from her R hand to pry client demonstrates
the fingers from the handle on approximately 20° of active
5/5 attempts. finger extension when extra
time and focus is dedicated to
the movement.

Analysis (A): The client was a very sweet and optimistic individual, that was very dedicated to

improving her LUE function in tasks related to meal preparation and home management. The

client demonstrates improvement with active finger extension and forearm supination; however,

the client’s tone continues to be a barrier while participating in functional activities. The client

demonstrated excellent potential to make progress in therapy; but the client was unable to make

all therapy sessions and the inconsistency of therapy, due to fieldwork and spring break, may

have been a barrier that interfered with the client’s success. The client’s tone and priorities
caused treatment to be solely focused on the LUE; therefore, leaving little time to address the

client’s goals related to balance.

Plan (P): OT services for this client will be discontinued as the adult OT semester is coming to

an end. Upon discharge, it is recommended that the client continues to receive skilled OT

services at the U of U Sugar House Health Center to improve left upper extremity function in

order to enhance occupational performance in all meaningful and desired ADLs and IADLs. The

client would benefit from continued OT services in order to improve active extension of the

fingers, full supination of the forearm, as well as isolated finger movements in the left hand. The

client demonstrates excellent potential to further improve within all the movements mentioned

above. The client would also continue to benefit by continuing to participate in the music glove

as part of her home exercise program, in addition to completing as many ADLs and IADLs as

possible with the use of the left upper extremity.

Lindsey Ward, OTS _________________________________________________April 13, 2018