BACKGROUND INFORMATION

Client’s name: Client (TP)

Date of referral:
Date of report: 4/16/18
Age: 52
Primary intervention diagnosis/concern: Right Side CVA
Secondary diagnosis/concern: Depression
Precautions/contraindications: N/A
Reason for referral to OT: left side hemiparesis
Reason for discharge from OT: End of Student Led Occupational Therapy 8-week program
Therapist: Jessica Brauzer, OTS, Meghan Berry, OTS

S: “My hand is already pretty fatigued from dealing the cards”-our clients response when asked to

incorporate her L hand during a card game of Rummi.

O: Our client participated in an occupational therapy program led by student therapists for 1 hour a week,

for 8 weeks. The client was seen to address improving engagement of LUE, and improvement of fine and

gross motor control of LUE. The client’s goals were to functionally incorporating her L UE into

ADLs/IADLs, more specifically: lower body dressing, fasteners, and home management tasks. At the

beginning of therapy, client was utilizing her L UE for 50% or less of functional tasks, including simple

meal prep, washing dishes, and folding laundry without direct verbal cueing. Education was provided in

the first two sessions to prioritize and adjust compensatory postures and movement out of her flexor

synergy pattern. Client was given a home exercise program which included mirror therapy and a visual

schedule to incorporate her left hand in two tasks during the upcoming three weeks. She was asked to

record how often she incorporates her L UE on a calendar reminder sheet. Therapist also utilized task-

specific training to functionally incorporate L UE and improve fine and gross motor skills of the LUE that

could be translated to occupations outside of the clinic. Movement out of synergy was difficult and

caused fatigue.

Long Term Goals Initial Performance Ending Performance

By discharge, client will
independently fasten an upper
body garment with use of
compensatory strategies. (Goal
met)
Client was unable to fasten Client independently zipped up
buttons without physical her jacket while on her body.
assistance, and was unable to zip
up her jacket while on her body.
 By discharge, client will Client was incorporating her Client incorporated her LUE in
independently incorporate LUE LUE in dishes and laundry task dishes and laundry tasks for
100% in dishes and laundry for 50% of the activity with 4-5 90% of the activity, with 1-2
tasks. direct verbal cues required. direct verbal cues.

A: Client made good progress, met one of her long-term goals and was very close to achieving her other.

Client is aware of maintaining upright posture when performing functional activities to be working

towards movement out of her flexor synergy pattern. She has also self-reported that she has been

successfully incorporating her LUE into more functional tasks in her daily life. She was very proud of her

progress in therapy. Client showed continued motivation throughout the sessions to respond well to

therapist cueing and work towards desired outcomes of therapy.

P: Client will continue to utilize home exercise program to strengthen fine and gross motor control of L

UE. She will also continue to be mindful of functional incorporation of her L UE and seek out

opportunities in the community to get involved in social outings. Client was provided with resources for

senior center and recreation center near her home, and the University of Utah rehabilitation centered

Stroke Camp commencing in the summer of 2018.

Sign: Meghan Berry

Date: 4/16/18