Cambry Kaylor

OC TH 6220

Occupational Therapy Discontinuation Report

Date of report: 04/25/2014
Name: Chris Jones
Date of birth &/or age: 70
Date of initial referral: 1/16/2014
M F
Primary intervention diagnosis/concern: RCVA
Secondary diagnosis/concern: Left inattention, Left hemiplegia
Precautions/contraindications: None
Reason for referral to OT: Community Client
Reason for OT discontinuation:
Therapist: Cambry Kaylor, OTS; Danielle Oberg , OTS
Description of OT Intervention:
Client was seen in his home for 60 minute sessions 1-2x/month for 3 months for 5 total visits.
Interventions addressed left inattention and high tone in the LUE in ADLs identified by the
client. Interventions included bed mobility and AE education, utilizing ipad apps to address left
inattention, UE mobilization through PROM, and meal prep tasks to decrease tone and increase
left attention. Kasey Mitchell, OTR/L came to the last session and educated the client on
techniques to increase left attention and decrease anxiety associated with the inattention.

Brief summary of progress towards goals:

Client demonstrated progress towards goals in the first three sessions. Client was able to meet his
first LTG and demonstrated proper use of AE and bed mobility techniques to roll to both the right
and left side of his body in bed with modified independence. Client showed functional mobility
digression over the five sessions in that he refused to use the walker or work towards standing
grooming task as previously identified. Since client made no progress toward his second LTG,
goals were adjusted to address high tone and left inattention to complete meal prep tasks. During

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OC TH 6220

the fourth session, the client demonstrated increased PROM/AROM in LUE however, during the
fifth session, the client demonstrated decreased LUE PROM/AROM and increased tone in the
LUE. Clients wife reported he was due for Botox injections in the LUE to decrease tone
following discharge. Client did show increased attention to the left with min verbal cueing over
the course of therapy.

Occupational therapy outcomes:

Initial performance in areas of occupation:
The Canadian Occupational Performance Measure (COPM) was initially administered was
utilized to establish client-centered goals and intervention planning. As therapy progressed,
clients goals and focus shifted to more occupation-based goals related to his left-inattention and
incorporation of the left hand specifically, meal prep and the COPM was not re-administered due
to these changes. Initially client was dependent on turning in bed, required direct verbal cueing
to attend to the left, and min to mod assist in meal prep activities.

Current level of performance in areas of occupation:

Following therapy, client is able to turn in bed with modified independence utilizing techniques
and AE provided by therapy students. Client still requires direct verbal cueing and verbal
encouragement from spouse to attend to the left due to anxiety associated with left inattention.
Client requires min assist in meal prep activities due to high tone and poor motor control in the
LUE due to inconsistency of use. While the clients performance may not have marked
improvement towards all his goals, according to the Client Satisfaction Scale 3, he strongly
agrees that therapy was useful and helped him with his problem areas.

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OC TH 6220

Contextual aspects related to discontinuation:

Client will continue to live with his wife who remains the primary caregiver. Wife is educated on
techniques to increase left attention including standing on his left and having him make eye with
her when interacting. Both the client and his wife are also educated on the importance of
repetition and incorporating the LUE in activities of daily living as much as possible.

Discontinuation recommendation:
Recommendations for discharge include incorporating LUE in daily activities and wearing L
hand splint for an hour a day to improve extension and tone in LUE. Wife will provide verbal
cueing as previously mentioned to facilitate left attention in client. Client will continue to see
outpatient PT services and attend wellness clinic once a week to address fatigue. Client will also
continue to see physician for Botox injections every six months in order to decrease tone.

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