Discharge note

Client: XXXXXXX
DOB: xx-xx-xxxx
Diagnosis: L CVA
Medical Hx: 2 years post L CVA, expressive aphasia, seizures, R visual deficits
Date of report: 4/21/16
Reason for referral to OT: To receive treatment to help improve function in RUE
Reason for discharge: The 8 week therapy program with an OTS ended.
Therapist: Brynnan Halsey, OTS
S: Client becomes frustrated when a task gets too difficult, but if the task can be adapted to be
more meaningful for him he can be reengaged.
O: Client was for OT services 1x/wk for 8 weeks to address R hemiparesis. Therapy focused on
educating the client on how to mobilize and reduce tone in his RUE using SROM and weight
bearing techniques. A majority of therapy sessions focused on teaching him to incorporate his
affective RUE into daily tasks as a stabilizer. He was given a leg lifter to help him get his affected
RLE over the edge of the tub when getting in/out. During the first few therapy sessions, the client
had difficulty engaging in the activities and would quit and push the activity away. After
revaluating his goals the sessions were changed to fit his needs and want, which led to improved
engagement. A final COPM was not given due to a language barrier and the clients expressive
aphasia.
Long-Term Goals
In 6 weeks, client will be able to
incorporate R UE into bilateral
tasks as a functional assist (e.g.
dressing and meal preparation)
with mod A.

Initial performance
Client required VC to use RUE in
bilateral tasks and Max A to open
the hand in order to grip and
stabilize objects with R hand

LTG2: In 6 weeks, client will be

able to independently complete
dressing with preferred clothing.

Client was able to I buttons of a

shirt while the shirt was laying on
a table, needed min A while shirt
was on, and needed mod A to
complete zipping. He required
VC to use RUE as a stabilizer

Ending performance
Client will spontaneously initiate
using RUE in bilateral tasks and
can open hand I using LUE if he
has not exerted too much effort.
If effort has been used then he
needs min-mod A opening hand
to use as a stabilizer during
bilateral tasks
This goal was discontinued on
3/24/16 as client signified it was
no longer a priority.

A: Client did show progress with function in RUE. He was able to achieve one of his initial goals
of using his RUE more functionally in daily tasks. By incorporating his RUE into more tasks the
clients occupational performance has improved over the course of therapy increasing his
participation in desired activities. The client engaged more when the tasks were more physical
and exercised based and the obvious occupational meaning was removed. The client is more
aware that he needs to incorporate his RUE into bilateral tasks in order to help rebuild the neural
motor pathways to the brain that were affected by his stoke and is continuing to work on this at
home. The barriers that continue to affect the clients progress are his dysphagia and his low
frustration level, which affect his ability to communicate his needs or try more challenging tasks.
The client has a lot of support from his family, he is attending ST, and he has a desire to keep
seeking out OT services all of which support his ability to continue progressing towards
occupational goals and improving functional performance in his R side.

P: Client will continue implementing practices he learned in therapy into his home routine. It has
been recommended that he continue to seek skilled OT services to help improve R hemiparesis.
He was provided with several OT options available through the Life Skills Clinic including the
Mastering Meaningful Movement class, the summer therapy program, and private self-pay
options. It was also recommended that the client continue attending ST to address expressive
aphasia and seek PT services to help R hemiparesis and walking difficulties.
Brynnan Halsey
4/21/16