Occupational Therapy Discharge Summary

Background Information:
Client’s name: Client (AM)
Date of initial referral: 1/25/18
Date of Report: 4/12/2018
Date of Birth: 7/6/1956
Primary Intervention diagnosis/ concern: Huntington Disease, TBI, CVA, Dementia
Secondary diagnosis/ concern: Expressive Aphasia, Ideomotor Apraxia, right-sided weakness
Precautions/contraindications: Walnut allergy
Reason for referral to OT: Difficulties with eating with utensils, inability to transfer in and out of car and
bed
Reason for discontinuation of OT: Client completed semester long therapy program with OT students
Therapists: Gabby Skoczylas OTS, Kenzie Smith OTS

S: Caregiver informed us that AM’s w/c tipped over before the therapy session, causing him to fall. She

was able to protect his head from the fall.

O: AM received occupational therapy services from OT students once a week for a total of 8 weeks. His

goals of self-feeding and transfers were addressed through the use of task specific training and other

functional and meaningful activities. AM met all of his self-feeding goals which included producing a

functional grasp, calibrating the utensil to mouth movement, and decreasing the amount of spilling

within a given feeding task. AM met his transfer goals of demonstrating improved endurance and

transferring in and out of a w/c with Min physical assistance and Min direct VC. He did not meet his goal

of demonstrating proper body positioning. A few weeks into the therapy, AM and his caregiver were

provided with an HEP addressing his feeding and transfer goals. During the last session, on 4/12/18, AM

required Mod direct VC and Min physical A to correct hand placement on utensil during feeding task.

While standing at a sink to wash dishes, he required Min physical A and Min direct VC to maintain

balance and distribute his weight equally.

Long-Term Goals Initial Performance Ending Performance

By discharge, Client will AM was unable to self-feed AM is now able to self-feed
independently self-feed with effectively without spilling food independently and effectively
less than 3 spills. on his clothing or the table without spilling his food more
several times. than 2 times.
 By discharge, Client will transfer AM required Mod-Max verbal AM required Min physical A and
in and out of wheelchair w and physical assistance to Min direct VC to perform sit to
MinA and Min direct VC to complete a wheelchair transfer. stand transfer.
enhance functional mobility.

A: AM has made excellent progress. His self-feeding goals were met due to task-specific training during

sessions and caregiver implementation of the HEP. He met two transfer goals due to repetitively

practicing car transfers and sit to stand transfers during the sessions. Caregiver reinforcement of HEP

also facilitated the accomplishment of these goals. He was unable to meet his transfer goal of proper

body positioning due to AM missing several sessions, as well as an overall limited number of therapy

sessions. AM’s need for an increased amount of verbal cueing and physical assistance during the

feeding task in the last session was due to his fall, which strained his energy, as well as due to him

having a week off from therapy last week.

P: AM will be returning to participate in this student based therapy program next year. He and his

caregiver will continue implementing the HEP that was provided a few weeks prior to discharge. He will

continue practicing his functional grasp and calibrating his hand movement. Caregiver will enable him

to practice standing from his w/c during functional tasks in order to increase his endurance and body

awareness.

Sign and date: Gabriela Skoczylas, OTS 4/12/18

LTG #1: By discharge, Client will independently self-feed with less than 3 spills. (GOAL MET on 3/29/18)

STG #1a: Within 2 weeks, Client will calibrate utensil to mouth movement with min verbal cueing. (GOAL

MET on 3/29/18)

STG #1b: Within 2 weeks, Client will demonstrate effective right handed grip when independently self-

feeding without dropping utensils. (GOAL MET on 3/29/18)

LTG #2: By discharge, Client will transfer in and out of wheelchair w MinA and Min direct VC to enhance

functional mobility. (GOAL MET on 4/12/18)

STG #2a: Within 2 weeks, Client will demonstrate proper positioning of body, with Min verbal cueing, in

order to transfer in and out of wheelchair.

STG #2b: Within 2 weeks, Client will demonstrate improved endurance by completing 2 transfers within

a session with ModA. (GOAL MET on 3/29/18)