OCCUPATIONAL THERAPY DISCHARGE SUMMARY

BACKGROUND INFORMATION
Date of report: 3-6-20 Client’s name: Client
Age: 52 Date of referral: 1-17-20
Primary Intervention diagnosis/concern: Traumatic brain injury
Secondary diagnosis/concern: Non-fluent expressive aphasia
Reason for referral to OT: Increase independence in IADLs
Reason for discharge from OT: Goals were met
Therapist: Raquel Perea, OTS & Trisha Snow, OTS

S: “You have really helped me alot...I’ve learned alot..I’m going to miss coming here.”
O: Client was seen in the occupational therapy clinic once a week for 8 weeks. Client was
taught cognitive strategies to address deficits in working memory, alternate attention, task step
initiation, and task step termination, which have affected IADL performance. Client was taught to
use checklists during laundry and food preparation tasks and utilize a daily task calendar.

Long-Term Goals Initial Performance Ending Performance

In 1 week, client will complete
IADLs assigned per caregiver
using a daily schedule with
min indirect VC.
Client did not utilize a daily
schedule and infrequently
performed IADL tasks.
Client used a weekly
calendar at home, with 3
IADL tasks assigned per day.
He required min VC from
caregiver to remember to
check the calendar. Client
was independent in
completing the IADL task and
checking the task off on the
calendar, once prompted to
check calendar.

During food preparation Client completed 30 steps of

Client will perform IADL tasks activity, client frequently a food preparation activity,
using a checklist strategy with became distracted and forgot with 1 indirect VC for initiation
min VC. to turn of the oven burner. to use the checklist strategy.

A: Client achieved his occupational therapy goals. He is working with his family to make a
weekly task calendar and create checklists for IADL tasks that require safety awareness.
P: Client will re-engage with a support group he previously attended, to increase social
participation. He will request an OT driving assessment from his physician, to evaluate his ability
to drive.
Raquel Perea, OTS 3-6-2020
Signature Date