Occupational Therapy Discharge Note

Date of Report: 04/13/18 Client’s initials: K.A

Date of Birth/age: 72 Date of referral: Fall 2017
Primary Intervention diagnoses/concerns: R.CVA
Secondary diagnosis/concern: n/a
Precautions/contraindications: n/a
Reason for referral:
o to improve function LUE to increase participation in ADLs and IADLs
Student therapists: Alexa Holguin & Angie Blaser

S: “I changed a light bulb in my house this week by myself!”

O: K.A was seen for 9 sessions and the University of Utah Life skills clinic to work on dressing and meal
preparation ADLs/IADLs. During these sessions, the client was taught compensatory techniques to open jars
and cans during meal preparation tasks and how to use a button hook to increase efficiency for donning UB
clothing. He was instructed on techniques such as visual imagery and pacing, to anticipate and prevent safety
concerns while making and reheating meals for himself. Over these two months, the client engaged in task
specific training during home maintenance, leisure, dressing, and meal preparation tasks to improve UE motor
control in his LUE. During this session, the Modified Ashworth was re- administered, in addition to observation
of occupational performance. The client made a complex stovetop meal with SBA, but required mod A to
prevent spillage of a hot container when he was transporting it from the microwave to the dining table. At the
end of the session, the client rated his satisfaction of treatment using the Client Satisfaction with Therapy and
Therapist Scale.

Long-Term Goals Initial Performance Final Performance

By discharge, client will I complete
upper body and lower body
dressing utilizing compensatory
strategies within a reasonable
amount of time per client report.
By discharge, the client will
prepare a 5-step meal with SBA
for safety
Client reported dressing would at
times take up to two hours when
he was getting ready for church.
He was observed donning a snap-
up shirt in 8 minutes with
frequent breaks
Client did not anticipate any
challenges. He required min.
direct vc for how to execute the
steps of the recipe. He was given
physical guidance to grasp scissors
Client self-reported that he could
complete his entire dressing
routine in approximately 30
minutes.
He could use a button hook to don
a formal shirt more efficiently
Prior to starting the task, the
client anticipated that boiling
water might be difficult and
problem solved how to make it
safer. Client performed a complex
 and cooking utensils safely.
Moderate physical assistance to
put pizza in/out of oven.
stovetop meal prep. task with
SBA, except he required mod A to
transport a hot bowl out of the
microwave. Client independently
opened all ingredients with
scissors safely and heeded recipe
instructions w/o verbal cues from
the therapist’s.

Modified Ashworth Scale (Grade 0: no increase in tone; 4 rigid tone)

movement Initial evaluation Final evaluation
RUE-all movements 0 0
LUE- elbow extension, pronation, 0 0
wrist flexion, finger flexion,
LUE elbow flexion 1 1
LUE supination 2 1
LUE finger extension 4 3

A: The client achieved his dressing goal and is progressing toward his cooking goal. The client was able to
perform UB dressing more efficiently and within a reasonable time per self-report. During meal preparation,
the client has improved his insight, problem solving, and occupational performance. He is able to anticipate
challenges and complete the steps of a recipe, but it is not recommended that the client transport heavy
objects out of an oven or microwave without supervision and SBA. During the tone re-assessment, the client
demonstrated decreased tone for supination and finger extension in his distal LUE. The client has been
satisfied with his increase in voluntary movement in his L. shoulder and is still making improvements with LUE
voluntary movement and motor control. This week the client also reported engaging a home maintenance
activity without any assistance, which he rarely has been able to do since after the stroke. The client has made
good progress in therapy and towards reaching his occupational goals of increasing performance with
dressing, meal preparation, and home-maintenance ADLs/IADLs.

P: the client will continue outpatient occupational therapy services at the sugarhouse rehabilitation clinic
1x/week and attend community programs,

Signature:
Alexa Holguin, OTS