S: The client’s wife said, “His hand was tight today from his UTI. I couldn’t get it open.

That’s

why he isn’t wearing his splint.”

O: The client was seen at the clinic for 55 minutes, to address standing tolerance and

positioning of his L UE. The client’s wife was educated on PROM techniques to open the client’s

L hand, stretching the thumb into abduction, then stretching the joints of the digits individually

until an open hand is achieved. The client completed 4 circuit board puzzles standing at the

counter. With his weight on his R leg and supported against the cupboards, his L leg was bent,

requiring 3 direct v/c’s to straighten his L leg and evenly weight bear. The client stood for the

duration of each puzzle, varying between 5 to 8 minutes, requiring 2 minute breaks between

puzzles. The client independently brought his L UE to the counter 4 times. The client shifted his

body to the L, leaving the board and pieces on his R. For puzzle completion, the necessary

pieces were removed from the box and laid directly in front of the client. He required 8 direct

v/c’s, 2 indirect v/c’s, and 2 demonstrations to select and place the puzzle pieces. The client

met and exceeded his goal of positioning his L UE on the table with no more than 2 direct v/c’s.

A: Education on PROM was provided due to the wife’s concerns. However, it will be important

to allow the wife to demonstrate stretching his L hand in the following session as the client’s

hand had already been passively stretched by the therapist, removing the wife’s ability to apply

the education with increased muscle tone. The client demonstrated good strategies for

compensating for his L visual field cut as he shifted his standing position to move the puzzle into

his R visual field. The client improved in positioning of his L UE, as he independently brought his

arm to the counter 4 times before starting the puzzle. More consistency is needed across

sessions to determine if the client has met his LTG. A STG for standing tolerance was added this
week as the client is making good progress in his goals, but is limited in positioning his L UE

during meal prep due to low standing tolerance. Positioning of his L UE in meal prep increases

his overall activity tolerance due to decreased shoulder pain. The task motivated the client to

stand for the completion of the puzzles, increasing his standing tolerance by 3 minutes from a

baseline of 5 minutes. However, the task was challenging to the client, cognitively indicated by

the large amount of cues required.

P: The client will continue to be seen once a week, for 2 weeks, for 1 hour sessions. Continued

skilled occupational therapy services are needed to address pain and positioning of his L UE in

daily tasks for shoulder stability and standing tolerance.

LTG 2: By discharge, the client will position his L UE during meal prep to decrease pain and

instability with no more than 3 indirect v/c’s. 

STG 2B: In 1 week, the client will remember to position his L arm on the table, using a self-

cueing strategy, with no more than 2 direct v/c’s.  GOAL MET 4/1/21

STG 2C: In 2 sessions, the client will increase standing tolerance to 10 minutes to complete meal

prep tasks at the counter.

Kaitlin Brown, OTS, 4/1/21