Occupational Therapy Discharge Summary

Background Information
Date of report: 4-23-16
Clients Name: BJ
Date of Birth: 12-24-1931
Date of referral: 1-20-16
DX: RCVA
Medical Hx: 6 bypass surgeries, 3 strokes, HOH, bilateral hearing aids
Medication: Lisinopril- for blood pressure
Reason for referral to OT: Overall weakness and balance, especially on left side
Reason for discharge from OT: Client fell and broke his right hip and is now in a
transitional care unit.
Therapist: Dawn Yearsley, OTS
S: We are sad that we had to cut our therapy short. His wife told us after he had
broken his hip.
O: Client was seen for OT 1x/wk for 6 sessions. To identify occupational areas that
needed to be addressed a semi-structured interview and part of the LOCTA were
performed. He and his wife were educated on techniques to help improve his
working memory and how to communicate with each other to help him understand
directions. Client was taught compensatory strategies to help him perform home
management skills such as hanging up clothes and doing the dishes. Client was
provided with verbal support and encouragement during sessions. Client willingly
participated in each therapy sessions. We were unable to readmit the interview and
LOCTA due to the client having to quite therapy secondary to falling and breaking
his hip.
Long-term Goal
By discharge client will
independently perform
home management skills
(e.g. laundry, dishes)
using compensatory
strategies.

Initial Performance
Clients occupational
performance and role
competence had
decreased. Client had a
hard time orienting the
shirt when hanging it up.
His wife reported that he
no longer did the dishes.
Client felt like his wife did
everything for him.

By discharge client will

participate in at least one
meaningful activity per
week.

Clients quality of life had

decreased sleeping all
morning and then only
participating in therapy.
Client expressed a

Ending Performance
Clients occupational
performance of hanging
up his own clothes
improved. Clients role
competence improved
when he felt like he could
lay out his own clothes in
the morning. Client was
able to hang up 3
different types of shirts
correctly and could
identify front/back, top
and bottom. He was able
to do the dishes with no
verbal cues.
Client tried molding clay
and asked if he could take
the supplies home to
keep working on it. This
shows a desire to improve

disinterest in almost
everything on the interest
survey except for pottery.
He stated that he no
longer goes to plays,
concerts etc.

quality of life. He is
starting to take steps to
fill his time in a more
fulfilling way.

A: Client met his 1st LTG and was making progress on his second LTG. Client really
liked the visual schedule that was created to help him remember what he had to do
each day. Client contributed to the design and what was included in the schedule.
Therapy services had to be discontinued early due to client breaking his hip. He is
currently in a transitional care unit for the next few weeks. Client reported he will
receive therapy through home health.
P: Client will continue OT care at the transitional care unit where he is currently
staying. When he is able to return home client will continue to explore areas of
interest.

________________________
Dawn Yearsley, OTS