Occupational Therapy Discharge Summary

Date of report: April 15, 2020

Client name: Client
DOB: Unknown
Primary intervention diagnosis/concern: 4 L-sided CVAs on September 7, 2020. The client has
damage to both sides of the cerebellum and pons.
Secondary intervention diagnosis/concern: Concern – decreased motivation and occupational
participation.
Reason for referral to OT: Seeking services to address deficits due to L-sided CVAs.
Reason for discharge from OT: Completed 8-week outpatient program.
Therapist:
S: “I can relax my fingers and then bend them all in, they just don’t go back out.”
O: Client was seen for OT 1x/week for 8 weeks. Within therapy, the client participated in task
specific training, repetitive movements, and fine motor tasks, and was given education on how
to manage tone of his R UE and R LE. The client also learned about the importance of using his R
UE as much as possible to create new neural pathways to increase active movement. Additional
strategies taught and used throughout therapy include weight bearing and self-ROM exercises.
These strategies were implemented in activities involving self-care ADLs such as shaving, nail
care, and full body dressing to lead to occupational performance improvement. Interventions
also addressed the client’s role competence as a 25-year-old adult to increase independence, so
less assistance is required from his mother. Interventions also addressed the outcome of
participation by addressing the client’s goal to complete full body dressing including donning
and doffing his AFO through compensatory strategies. In place of a formal administration of the
COPM, throughout therapy and during the last session before discharge, client reported an
overall increase in performance and satisfaction in identified occupational priorities compared
to the start of therapy. According to the client satisfaction questionnaire, the client is satisfied
in the OT services he received.

Long-Term Goals Initial Performance Ending Performance

By d/c, client will Completed 50% of total body Completes 90% of total body
independently dressing. Mod-max A in donning dressing. IND in donning AFO,
complete total body AFO, min A for dressing, mod A IND in dressing, min A required
dressing with AE as for tying shoelaces. R UE does for tying shoelaces. R UE
needed. not assist. assists in task.
  

By d/c, client will

independently
complete grooming Completed 60% of grooming and Completes 100% of grooming
and hygiene as part hygiene. Min A in shaving, mod- and hygiene. IND in shaving,
of a morning max A in nail care. R UE does and IND in nail care. R UE
routine. not assist. assists in task.

A:  Client reached STG 1a to IND don/doff AFO. The client did not reach STG 2a in that
he requires min A to tie his shoelaces but made progress from mod A. The client met
LTG 2 in that he is IND in shaving and nail care. The client made great progress in
incorporating his R UE during tasks. The client also made great progress in
implementing strategies to manage his R-sided tone such as relaxing his R UE to his
side and by flexing his R LE while standing. The client seemed to be encouraged to
continue to make progress after discharge by following the home program provided to
him. The client’s mother is a support to continue assisting him as needed but may also
pose as a barrier in that she may assist the client more than needed.

P: Client will engage in home program recommendations with the support of his mother.
Client will continue to use his R UE as much as possible by incorporating it into ADLs
and IADLs such as dressing and grooming/hygiene along with other everyday tasks.
Client will incorporate learned strategies to manage tone when needed.
GAS chart
**HINTs: each column should have 3-5 bulleted measures.
***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.
Distal Outcome -2 -1 0 +1 +2
(LTG 1): (Baseline) (Goal)
By d/c, client will Much Less Less Expected Level Better Much Better
independently
complete total
body dressing
with AE as
needed.

(Occupation/Target Requires max A to Able to Able to Able to Able to

Behavior) don leg brace, independently don independently don independently don independently don
shoes, cannot do slip on shoes and pullover shirt, loose jacket with zipper. jeans and button-
fine motor don leg brace with pants, shoes with down shirt.
 manipulation for min A. laces, socks, and
laces and fasteners. leg brace.

Proximal Outcomes (STGs) Measurement Criteria Baseline

1a) In 4 weeks, client Able to independently do and doff leg Requires max A to don/doff leg brace.
will independently brace.
don/doff AFO.
2a) In 6 weeks, client Able to independently don shoes and tie Requires max A to don/doff shoes and tie shoelaces.
will independently don shoelaces.
shoes and tie
shoelaces.

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.
Distal Outcome -2 -1 0 +1 +2
(LTG 2): By d/c, (Baseline) (Goal)
client will Much Less Less Expected Level Better Much Better
independently
complete
grooming and
hygiene as part
of a morning
routine.

(Occupation/Target Able to shave face Able to shave face Able to Able to cut toenails Able to
Behavior) with mod assist, with min assist, able independently with min A. independently cut
bites fingernails, cut fingernails with shave face, cut toenails.
able to apply mod A, and apply fingernails, and
deodorant with min deodorant apply deodorant.
A. independently.
Proximal Outcomes (STGs) Measurement Criteria Baseline
1b) In 6 weeks, Able to independently cut fingernails with Requires max assist to complete nail care.
client will the use of adaptive equipment.
independently
complete nail care
with AE.
2b) In 4 weeks, Able to independently remove facial hair as Requires mod assist to complete facial hair removal.
client will part of a morning routine.
independently
complete facial hair
removal.

Signature: Tayler Stokes, OTS

Date: 4/15/2021