Stacie Bryant

OC TH 6220
4/20/17

Occupational Therapy Discharge Report

Date of report: 4/20/17
Clients name: D.M.
Date of referral: 1/21/17
Date of birth/age: 2/25/86, 30 years old
Primary intervention diagnosis: RUE
hemiplegia due to CVA 11/2015
Secondary diagnosis: Moderate
dysarthria, mild aphasia, diabetes, lupus
Precautions/contraindications: R
shoulder pain, RUE spasticity/high tone
Reason for referral to OT: ADLs and
IADLs with RUE
Reason for discharge from OT: Goals
were met
Therapist: Stacie Bryant, OTS

S: The client states that he feels like things are going better for him functionally, but that he

is still not where he wants to be.

O: The client was seen in the Life Skills Clinic for OT once a week for 7 weeks. The clients

RUE was treated with joint mobilization, PROM, and weight bearing prior to functional tasks

to manage spasticity and improve range of motion. The client also participated in RUE

grasp and release preparatory activities prior to functional activities to reinforce motor

patterns. Task specific training completed with the client focused on the occupations of

bathing, meal preparation, feeding, and tying shoes, which reflect his identified priorities for

therapy. Education was provided in regards to energy conservation, incorporation of RUE in

functional tasks, and stabilization of RUE to improve fine motor accuracy. Theraputty and

finger extension exercises were provided for his home exercise program, as well as

additional shoulder ROM exercises. He was also provided with a shoe-tying aid for practice,

as his shoes do not currently have long enough laces for him to successfully practice with.

The COPM, Fugl-Meyer, and the ABILHAND Questionnaire were completed upon

initial evaluation and discharge.

COPM reported scores initially and at discharge:

OP Problems Initial Initial Discharge Discharge
Performance Satisfaction Performance Satisfaction
Rating Rating Rating Rating

Opening hand to 3 3 3 2
wash body

Cutting food 3 1 5 5

Tying shoes 1 1 2 1

Golf swing 2 2 4 4

Typing 5 3 3 3

Loading gun clip 2 2 3 3

Total Scores 2.6 2 3.3 3

Fugl-Meyer results initially and at discharge:

Initial PROM Score Initial Pain Score Discharge PROM Discharge Pain
Score Score

17/24 23/24 22/24 24/24

ABILHAND Questionnaire results initially and at discharge:

N/A 0 1 2

Initial Scores 4 activities 3 activities 10 activities 6 activities

Discharge Scores 7 activities 5 activities 6 activities 4 activities

The results from the COPM demonstrate an increase in performance with a change

score of .7, as well as an increase in satisfaction with a change score of 1. The Fugl-Meyer

demonstrates a decrease in pain and an increase in PROM. The ABILHAND Questionnaire

results indicate a decrease in performance of bimanual activities. The Client Satisfaction

Evaluation was also provided at discharge, and is attached. The clients progress from

baseline toward goals are as follows:

Long-Term Goals Initial Performance Ending Performance

By discharge, D.M. will The client required max The client independently
independently tie shoes utilizing assist for tying shoes tied laces with shoe on
compensatory strategies. while wearing them. table.

By discharge, D.M. will The client reported using The client utilized R hand to
independently cut food with a rocker knife to cut food, hold fork to stabilize food
dinner knife during meals while without utilizing his R while cutting with dinner
demonstrating knife safety. hand. knife with the L hand.

By discharge, D.M. will The client opened his R The client actively initiated
independently use R hand to hand by using his L hand and maintained R finger
wash left side of body during to extended R digits. extension for 10 seconds
bathing to his satisfaction. while washing L arm.

A: The client demonstrated good progress and achieved all of his goals. D.M. has

demonstrated progress in active R digit extension and the incorporation of RUE during

functional activities at home and in the clinic. The pain and stiffness in his shoulder has

decreased, and overall RUE passive and active ROM has increased. Initially, the client

required min assist in meal preparation, bathing, and grooming, and max assist in tying his

shoes. D.M. is currently independent in dressing, meal preparation, bathing, and grooming.

His outcomes in therapy demonstrate improvement in occupational performance, role

competence, and well-being. The clients motivation and effort displayed during therapy will

be his greatest support in continuing to regain function.

P: It is recommended that the client continue RUE PROM, weight-bearing, and finger

strengthening exercises with Theraputty at home. He will benefit from continued

incorporation of RUE in functional activities, especially with tasks that require finger

extension. It is also recommended that the client integrate energy conservation techniques

into his daily routine. The client is encouraged to continue PT and speech therapies, as well

as his daily exercise routine at the gym. These supports will further assist him in recovering

as much function as possible following his stroke.