Discharge note

Background information
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: Jilianne Normandy, OT/S

S: “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: The client was seen for skilled OT services at an outpatient setting 1x/week for 6

weeks for 1 hour to address his motor control in his RUE. He performed self PROM as a

preparatory task to reduce tone in his RUE. The client improved his ROM in shoulder

flexion (164 degrees) and shoulder abduction (145 degrees), however had no change in

finger MP flexion. The client was administered reassessments in RUE ROM, the Box

and Blocks test, the Canadian Occupational Performance Measure (COPM), and the

Client Satisfaction Questionnaire.

Box and Blocks retest results:

Hand Tested Number of blocks moved Number of blocks moved

T1- 01/25/2018 T2-04/12/2018

Right 7 8

Left 38 45
When his tone increased in his RUE during the test, he independently performed a tone

reduction stretch. However, he still used a raking grasp with digits 4-5 to pick up the

blocks with R hand.

COPM:

The COPM was re-administered to measure improvements in his satisfaction and

performance.

OT Problems Importance Performance Satisfaction Performance Satisfaction

Scored 1- Scored 1-10 Scored 1-10 Scored 1-10 Scored 1-10
10 T1- T1- T2 - T2 -
1= not 01/25/2018 01/25/2018 04/12/2018 04/12/2018
important
10= most
important

Put contacts 9 1 1 1 1
in

Cutting food 4 4 1 6 6

Donning socks 4 4 1 5 5
and shoes
biannually

Typing on 3 2 1 3 2
laptop

Managing and 2 5 1 3 3.5

handling
money

Average 3.2 1 3.6 3.5

Scores:

Change scores .4 2.5

AOTA Professional Development Tool (PDT): Client Satisfaction Questionnaire

A questionnaire was given to gather information on the client’s satisfaction with

the OT program and treatment, as well as his perception of improvement in his goals.
Overall, the client was satisfied with the OT program and was willing to participate in the

program next year. At the end of the session, handouts and resources were provided to

continue incorporating his RUE into activities and managing his diabetes.

Goals:

Long-Term Goals Initial Performance Ending Performance

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

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

A: The client has demonstrated improved ROM, elbow extension, grasp and release,

and lateral key pinch in his RUE due to receiving OT and utilizing his home therapy

program. He has demonstrated adherence to his A/PROM exercises and is aware of

preventing shoulder hiking during activities. Minimal improvement was shown in the Box

and Blocks test due to limited timing and increased tone in his RUE during the test,

however he has demonstrated incorporating compensatory strategies to manage his

tone. The client met his cooking goal, but did not meet his eye contact goal due to a

change in his priorities.

P: The client will be discharged from skilled OT services due to improvement in motor

function of his RUE. He will continue to work on grasp and release and fine motor skills

at another outpatient OT setting as well as continue his wellness program at

Sugarhouse Rehabilitation. He will continue his home therapy program to help reduce

tone and increase ROM in his RUE. Handouts were provided for the client that gave him

information on fine motor activities he could do around the house with his R hand as

well as P/AROM and strengthening exercises that he was able to demonstrate

competence. The client was also provided information about the Utah Department of

Health EPICC program, which provides a website and clinic locations for educational

classes to help manage his diabetes. The client was provided with suggestions to insert

reminders on his phone to incorporate his RUE during everyday tasks.

OT/S

4/12/2018