Occupational Therapy Discharge Summary

Date of report: April 22nd, 2021

Client name: MH
DOB: 10/02/1969
Primary intervention diagnosis/concern: L wrist disarticulation; R disarticulation at MCP,
thumb amputation with residual digit, proximal to the DIP.
Secondary intervention diagnosis/concern: 50% of total body surface area (TBSA) is grafted
secondary to motor vehicle accident three years ago. Visual impairment (specific dx unknown).
Reason for referral to OT: Seeking additional services to address deficits due to BUE
amputation regarding fine motor tasks in specific I-ADLs such as scissors use, resealable bags,
and wrench use.
Reason for discharge from OT: Completed all goals in 8-week outpatient program.
Therapist: Melanie Canna, OTS & H. Ellie Smith, OTS

S: “I am really excited about how much I have improved through the program!”

O: Client was seen for OT services 1x/week for 8 weeks at the University of Utah Occupational
Therapy Outpatient Clinic to address dissatisfaction with I-ADL performance in activities
including scissors use, resealable bags, and wrench use. After these three occupations were
addressed, additional occupations were added including lighting a candle and using a hammer.
Within therapy, Client learned about adaptive strategies and environmental modifications to
improve his performance in the stated I-ADL’s. Performance in all I-ADL’s improved
throughout the services as demonstrated by the COPM interview and GAS charts.

During the final session, client demonstrated the use of a hammer and nail to hang a photo on the
wall independently. During his first attempt he completed the task with no adaptive strategies in
approximately 8 minutes. Using adaptive strategies including a velcro strap to secure the hammer
to his R prosthetic, and a square piece of cardboard with a slit used to hold a nail, he
independently completed the same task in approximately 2 minutes. Client stated he was excited
to hang photos when he got home.

Client participated in a COPM interview during evaluation and discharge. The following data
was gathered regarding occupational performance on 2/8/21 and 4/22/21.

OCCUPATIONAL PERFORMANCE SATISFACTION PERFORMANCE PERFORMANCE

PERFORMANCE T1 (2/18/21) T1 (2/18/21) T2 (4/22/21) T2 (4/22/21)
PRIORITIES
1= I can’t do it at 1= I am not 1= I can’t do it at 1= I am not
all. satisfied with my all. satisfied with my
10 = I can do it performance performance
really well 10= I am 10 = I can do it 10= I am
extremely really well extremely
satisfied with my satisfied with my
performance. performance.
Using auto tools 4 1 4 7
– specifically
 wrenches
Scissors use 1 6.5 9 9
Resealable bag 2.5 2.5 8.5 9
use
Total 7.5 10 21.5 25
Average Scores 2.5 3.3 7.2 8.8

According to the client satisfaction questionnaire, the client is satisfied with OT services he
received.

Long-Term Goals Initial Performance Ending Performance

By d/c, Client will independently Using tools with assistance, not Client reports that he can complete
complete simple car repair with generalizing for car repair simple car repair with tools, using
tools, using adaptive strategies.  (Moderate Assistance) adaptive strategies. (Independent)
Needs to have son open and seal Open and close bags using the
By d/c, Client will independently plastic, resealable bags, at times packaged resealable bag.
prepare packaged food, using breaks open bag so it is not (Independent). Client reports being
adaptive strategies. usable. (Total Assistance) able to prepare food independently
with this new skill.
Needs to have others cut open Independently can cut complex
By d/c, client will cut coupons
packages, coupons. (Total shapes from various materials.
out of paper independently
Assistance) (Independent)
Light a candle independently with a
By d/c, Client will independently
Needs to have others light a match. (Independent)
light a candle using adaptive
candle (Total Assistance)
strategies
Can use a hammer to hit a nail, Client can use a hammer and nail
By d/c, Client will independently
but drops nail frequently. with adaptive strategies to put a nail
use a hammer to put a nail into
(Independent – but with into pressed wood in approximately
drywall to hang a photo.
significant amount of time) two minutes. (Independent

A: As indicated by the Long-Terms Goals chart above, client’s ending performance in

occupational priorities are higher for every I-ADL. He met his goals of being able to light a
candle, completing simple car repair, using a hammer and nail, and using prepared packaging of
resealable bags. He far exceeded his goal of cutting coupons by demonstrating the ability to cut
various materials and shapes using adaptive strategies. Client is independent in ADL’s and I-
ADL’s and no longer requires occupational therapy services. His sons at home continue to be a
positive social support for him by assisting him with requested occupations. Client is motivated
to share new knowledge about adapting occupations to other people with a similar condition and
received a handout outlining the strategies used in our session. This could be used as a tool as he
continues to serve as a mentor.

P: Client will continue to use general strategies, i.e., adjusting the environment, approaching
occupation from different angles, utilizing different securing materials, etc. to approach
challenges that come up in the future with I-ADL’s. Client will use home program hand-out to
recall specific strategies for I-ADL performance covered in therapy, and to assist as a mentor to
other amputees. It is recommended that client continue to volunteer as a mentor, work as a
 delivery driver, and seek assistance from OT’s if he has trouble adapting occupations to match
his abilities.

Distal Outcome (LTG): -2 -1 0 +1 +2

By d/c, Client will (Baseline) (Goal)
independently complete Much Less Less Expected Level Better Much Better
simple car repair with tools,
using adaptive strategies.
(Occupation/Target Behavior) Using tools with Using tools, not Complete simple car Complete
Complete simple car repair assistance, not generalizing for car repair with tools, simple car
with tools, using adaptive generalizing for car repair using adaptive repair with
strategies. repair strategies. tools, in
reduced
amount of
time.
Proximal Outcomes (STGs) Measurement Criteria Baseline
In three weeks, Client will Able to hold tool for approximately one Using tools with assistance, not generalizing for car
identify and utilize an effective minute while moving wrist: repair
grasp with car repair tools, -pronation Has not identified efficient grasp
using adaptive strategies and -supination
moderate assistance. -radial deviation
-ulnar deviation
Assistance level: mod A

By week 8, client will utilize
tools to screw and unscrew
bolts from various positions
and angles, using adaptive
strategies
Able to screw bolts on and off with minimal Unable to utilize carp repair tools from a variety of
assistance from different positions: positions, will need to complete STG 1 prior to this.
-sitting
-leaning left on support
-leaning right on support
-leaning forward on support
-reaching to the L or right (across midline)
Assistance level: min A

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
By d/c, Client will Much Less Less Expected Level Better Much Better
independently
prepare packaged
food, using adaptive
strategies
(Occupation/Target Needs to have son Assistance to retrieve Open bags with Open and close
Behavior) open and seal plastic, bags from packaging, scissors and store in bags using the
Store food, using resealable bags, at set up for opening and Ziplock brand bag. packaged
adaptive strategies. times breaks open bag sealing bags. resealable bag
so it is not usable.
Proximal Outcomes (STGs) Measurement Criteria Baseline
With set up and minimum Coordinate holding package and
assistance, in two weeks, client pulling out bag Dependent on others to open resealable bags
will retrieve resealable plastic Grasp bag
bags from packaging using Maintain grasp on bag and package to
adaptive strategies.
With setup, in five weeks, client
will open and seal resealable
plastic bags using adaptive
strategies.
pull bag out
Assistance level: min A
With setup, coordinate holding one
opening of the bag and spreading the Dependent on others to open resealable bags
two openings apart
Coordinate holding each side of the
opening of the bag with either hook

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
By d/c, client will cut Much Less Less Expected Level Better Much Better
coupons out of paper
independently..
(Occupation/Target Needs to have Able to cut some Cut coupons Can generalize straight Independently
Behavior) others cut open materials, only in independently. cutting skill to other can cut complex
Cut coupons. packages, coupons. straight line. materials shapes from
various materials.
Proximal Outcomes (STGs) Measurement Criteria Baseline
By week six, client will Client will independently Dependent on others to cut items.
independently open and close grasp scissors
scissors five times without Open and close scissors
dropping them. mechanism
Endure activity for at least
five times.

By week seven, client will utilize
scissors to cut snips from a paper
independently.
Secure scissors grasp while Dependent on others to cut items.
holding onto material to
cut
Align material with tool
Snip at least 10 times into
the bottom of contruction
paper.

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
By d/c, client will Much Less Less Expected Level Better Much Better
independently light a
candle using adaptive
strategies.
(Occupation/Target Needs to have Makes a flame but not Light a candle Able to use a
Behavior) others light a candle able to light a candle independently with a variety of lighter
Light a candle specific type of lighter or styles/shapes as
match. well as matches.

Proximal Outcomes (STGs) Measurement Criteria Baseline

By week 8, client will use an
efficient grasp on a lighter or a
match.
Client will hold lighter or matches Dependent on others to light a flame with a lighter.
in a way that allows for lighting a
flame.
Client will produce the flame
Client will move the flame to the
wick to light it.
Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
By d/c, Client will Much Less Less Expected Level Better Much Better
independently use a
hammer to put a nail
into drywall to hang
a photo.
(Occupation/Target Can use a hammer to Able to use a Hammer a nail Hammer a nail Hammer
Behavior) hit things but not able hammer and nail independently into independently into nails into a
Hammer a nail to generate enough with assistance of drywall. plywood. variety of
force to put a nail someone material
through the wall. stabilizing the nail types
or hammer.
Proximal Outcomes (STGs) Measurement Criteria Baseline
By week 8, client will use an Client will stabilize hammer in Able to hammer a nail into wood, however requires more
efficient grasp with a hammer. one extremity time than what feels appropriate to him.
Client will swing hammer
toward nail in a way that it does
not change the position of the
hammer.
Nail will go to desired depth into
material.

Signature: Melanie Canna, OTS

Date: 04/22/2021