Occupational Therapy Discharge Summary

Date of report: XXXXX Client’s Name: Client

Date of birth/age: N/A Date of initial referral: XXXXXXXX
Primary intervention diagnosis/concern: R CVA/high tone and decreased motor control
Precautions/contraindications: N/A
Reasons for referral to OT: Self Referral
Reason for discontinuation of OT: Services ended
Therapists: Jon Bateman OTS, Neesha Nixon OTS

S: “Oh wow, that actually worked!!”

O: Client was seen at the Life Skills Clinic for occupational therapy services, 1x/wk for 7 weeks.
Client’s LUE high tone, and decreased motor control was treated with AROM exercises, PROM,
scapular mobilization, and isolated finger exercises. The client also participated in education
with weight-bearing exercises to promote proprioception as well as neuro-reeducation via high
repetition UE tasks. Client was able to perform dressing independently after being instructed
how to use a button hook to facilitate dressing in business attire with multiple fasteners. The
client was also able to perform shoe tying independently after being instructed on a one-handed
shoe-tying technique to increase independence in his daily morning routine. High repetition
typing using LUE as well as isolated finger exercises improved his ability to hit home row keys
with L digits 2-5. Client completed the 3-minute typing test, 2x using BUE. First round, client
typed 9 WPM with 18 errors and second round, typed 8 WPM with 14 errors.

Long Term Goals Initial Performance Ending Performance

Client will be able to IND tie Client required multiple Client IND tied R and L
his shoelaces using attempts as well as direct VC shoelaces with effortful
compensatory strategies to complete the task IND. movements and extended
time.

By discharge, client will IND Client was unable to hit keys Client used all five digits.
type 15 words in 3 minutes with accuracy using LUE. Client performed accuracy
with no more than 4 errors. Client used only the L index better after maintaining
finger as well. proper posture.

1) 9 WPM with 18 errors = 3

2) 8 WPM with 14 errors = 4

Client will IND dress in
business attire using
compensatory strategies
The client required multiple
attempts (R cuff button, neck
button, cuff link, pant
fasteners), visual
demonstration, use of visual
feedback (mirror) or change
of body position as well as
direct VC before completing
Client completed dressing (R
cuff button, neck button, cuff
link, pant fasteners) IND with
effortful movements and
extended time.
 tasks IND.

The client initially completed the COPM at the beginning of treatment to identify priorities and
goals, however, priorities changed throughout the sessions due to completing initial goals; new
goals were identified and updated. New priorities/goals are shown below with current scoring.
Client showed marked improvement in both performance and satisfaction.

COPM :
OCCUPATIONAL PERFORMANCE Impt PERFORMANCE SATISFACTION PERFORMANCE SATISFACTION
PRIORITIES T1 T1 T2 T2

1.Keyboarding 9 4 1 5 3

2. Shoe Tying 7 1 1 8 10

3. Dressing (Dress shirts/pants) 6 5 5 7 5

TOTAL 10 7 20 18

Average Scores 3.33 2.33 6.66 6

A: Client met two out of three of his LTGs. He was unable to meet his typing goal due to the
number of errors as well as inefficiencies with maintaining correct posture throughout the task.
However, the client is aware of his current performance patterns and has reported he will
continue to work on it outside of therapy. He has demonstrated improved performance with
utilizing isolated finger movements with all 5 digits. The client demonstrated great problem-
solving skills as well as motivation towards independence that promoted his success with shoe
tying and dressing.

P: Client will continue to perform AROM using a wooden dowel as well as weight-bearing
exercises at home. Client will adjust the work environment to promote proper posture with typing
as well as continue to use LUE for typing as much as possible. Client will continue to use button
hook and compensatory strategies daily to continue towards independence and promoting
neural connections via high repetition tasks.

Home Exercise Program:

Isolated Finger exercises:

Implement these exercises frequently throughout the day.

 1. With palm and fingers flat on the table spread fingers open then close again.
2. Open your hand then close again. Alternate thumb into a fist and on top of the fist.
3. Make “o”s with thumb and each finger touching the tips together.
4. Crumple a sheet of newspaper into a ball with one hand, flatten it out again on a
tabletop.
5. Pick up coins and buttons of various sizes. Hold the coins in hand and pick up more.
With the coins/buttons in your hand move one at a time from the palm to your fingertips
and place in the slot. (ie piggybank)
6. Interlace fingers and turn palm out.
7. Roll pencil between thumb and fingers
8. Place palm flat on the table with fingers, raise one finger at a time.

Dowel Exercises:

Perform exercises listed below in the attached link: Dowel Exercises

Cross over

Arm Push Up

Side to Side

Shoulder Flexion

Additional Resources:

Dragon Assist: UCAT 801-887-9380

One-Handed Shoe Tying Technique:

https://youtu.be/UhmeN5w4sKg

Left Hand Typing Exercises:

http://www.typingme.com/touch-typing/typing-lesson-1.php

Typing Test with current scores:

www.typingtest.com

9 WPM with 18 errors = 3

8 WPM with 14 errors = 4

Signature: Jon Bateman & Neesha Nixon Date: XXXXXX