Discontinuation Discharge Note

Client: Client
DOB: 03/31/1951
Primary Diagnosis: multiple CVAs
Referral: referred by student speech clinic for an evaluation
Dates of Evaluation: 1/28 & 2/4/16
Date of Discharge: 4/21/16
Reason for Discharge: Goals were met
Therapist: Melanie Francis, OTS
S: Client and caregiver stated they really have seen improvements and are going to continue
wearing splint and doing stretches.
O: Client was seen for OT services 1x/week for 8 weeks. R UE was treated with joint
mobilizations, PROM, and AAROM. Client also participated in education on neuromuscular
reeducation including weight bearing and using her R UE as a stabilizer during occupations.
Clients goals were to improve the use of her arm in order to increase occupational performance
in bathing, dressing, house cleaning, and laundry. Interventions included joint mobilizations and
handling to improve use of R UE as a stabilizer and to weight bear during occupations.
Occupations used in therapy include meal preparation, household management (cleaning and
laundry), preferred leisure activity (gardening), and ADL (toileting). Client improved her
occupational performance, occupational participation, and well-being through this episode of
care.
Client completed the ADL-IADL Addendum to the Occupational Self-Assessment (OSA), which
measures the clients competence and importance of ADL and IADL occupations, with minimal
input from her husband. The results, listed below, indicate improvement in bathing, dressing, and
grooming. Meal preparation and house cleaning are still indicated as Lot of Problems but
Client did verbally indicate that they had improved as well. This self-report indicates her
improved occupational performance. Client also reported increased participation in all of her
desired goals which has improved her well-being.
ADL-IADL Addendum to the Occupational Self-Assessment
Initial Performance
Bathing
Lot of Problem
Dressing
Some difficulty
Grooming
Well
Meal preparation
Lot of problem
Toileting
Extremely well
Driving
Lot of problem
House cleaning
Lot of problem
Laundry
Lot of problem
Grocery shopping
Lot of problem

Ending Performance
Some difficulty
Well
Extremely Well
Lot of problem
Extremely well
N/A
Lot of problem
Lot of problem
N/A

Client was observed making a peanut butter and jelly sandwich. She opened, removed, and
placed bread on the plate (I). She used Dycem to stabilize the jars and plate while spreading the
peanut butter and jelly on the bread with mod(I). She required maxA to close the bread bag. She
(I) initiated the use of her R UE as a stabilizer. She sustained her attention throughout the task.
Client completed the AOTA Professional Development Tool (PDT) indicating overall satisfaction
with this episode of care.
Clients environment supports her occupational performance and participation with grab bars,
AE, supportive family, and a clean home. Some barriers remaining are her deteriorating knees
and multistory home which increases her dependence on family. She is determined to continue to
increase her independence despite these physical and environmental limitations.
A: Client made good progress as indicated by her self-reported improvement on the ADL-IADL
OSA addendum and her improved meal preparation performance. She achieved all of her goals.
P: It is recommended that Client continue with daily joint mobilizations and daily use of the
SaeboStretch splint for at least 1 hour periods. Also recommended is to continue to incorporate
her R UE in occupations as a stabilizer or for weight bearing.
LTG 1: By d/c, Client will use her affected arm as a stabilizer during meal preparation
with no more than 3 verbal cues. Goal met on 04/21/16
STG 1: In 3 weeks, Client will use her affected arm to prevent items from falling
off tabletop with no more than 2 physical cues. Goal met on 03/24/16
STG 2: In 6 weeks, Client will (I) initiate use of her affected arm during meal
preparation. Goal met on 04/21/16
LTG 2: By d/c, Client will safely transfer to/from w/c with minA for ADL participation. Goal met on 04/14/16
STG 1: In 4 weeks, Client will correctly position feet for transfer with no more
than 3 verbal cues for ADL participation. - Goal met on 04/14/16
STG 2: In 6 weeks, Client will safely transfer to/from shower chair with modA. Goal met on 04/14/16
LTG 3: By d/c, Client will use her affected arm as a weight bearer during transfers and
functional activities with no more than 3 VC to increase her occupational independence.
Goal met on 04/21/16
Melanie Francis, OTS
4/22/16