OCCUPATIONAL THERAPY DISCHARGE SUMMARY

BACKGROUND INFORMATION
Date of report: April 23, 2016
Clients name:
Date of birth &/or age: 53yo
Date of referral: Jan. 25, 2016
Primary Intervention diagnosis/concerns: Left CVA
Secondary diagnosis/concern: Expressive Aphasia
Precautions/contraindications: N/A
Reason for referral to OT: Symptoms of CVA are affecting participation in occupations.
Reason for discontinuation of OT: Client completed 9-week community program.
Therapist: Colton Savage, OTS; Liana Ho, OTS
S:

I have been riding a bicycle for a while now.

O: Client was seen on 4/19 in the Life Skills Clinic of the University of Utah. Client was
independently demonstrated understanding of arm strengthening exercises.
Client was seen at the University of Utahs division of Occupational Therapy building and the
Life skills clinic once a week for a 9-week program. Clients poor balance and core strength was
treated with core strengthening exercises. Clients poor hand strength was treated with home
hand strengthening exercise. Client also participated in education and social skills training to
successfully meet new people.
The goals for this client were based around the outcomes of improving occupational performance
and engagement.
Long-Term Goals
By discharge, client will
complete the process of
applying to be a volunteer at
the VA.
By discharge, client will bowl
one game without stumbling
more than 3 times.
By discharge, client will
initiate a conversation with an
unfamiliar person on 3
different occasions in one
week as reported by client.

Initial Performance
Client had not started this
process.

Ending Performance
Client is waiting on the VA to
finish their end of the
application process.

Client demonstrated difficulty

performing lateral flexion and
hand strength to successfully
bowl.
Client reported inability to
find words and initiate
conversations with unfamiliar
people.

Client bowled the equivalent

of over one game while
stumbling only once.
Client participating in
roleplaying with student
therapists in preparation for
real life implementation.

The COPM is an individualized measure that is used to determine priorities of occupational

therapy and to assist in establishing intervention goals. It is also used at a future time to
determine if progress has been made and the outcome of interventions. The results of
administration are as follows:

Occupational Performance
Problems
1. Meeting new people/Dating
2. Walking more
3. Going to gym more
Totals

Performance (1 not able to

perform occupation at all 10
able to perform occupation
extremely well)
5
5
5
5

Satisfaction with Performance

(1 not satisfied at all 10
extremely satisfied)
7
6
6
6.33

The clients goals changed from beginning of therapy to end, so comparison of scores to specific
goals isnt possible. That being said, the total scores of 5 performance and 6.33 satisfaction to the
first COPMs 3.5 and 4.0 show an increase in the clients opinions with his participation in his
life.
Client Satisfaction Questionnaire:
An American Occupational Therapy Association (AOTA) client satisfaction questionnaire was
administered to the client. Clients responses included having less difficulty in managing home
and community, being less dependent on others, and the activities in therapy focused on his
interests. He did state that he partially wished we worked on other activities, and was only
somewhat satisfied with the achievement in the program. His final comment consisted of the
simple statement: Good Job!
Supports and Barriers:
Client has minimal social supports. He lives alone at home with his dog, and his family lives out
of town. He doesnt get to visit his family as much as he would like. His dog has proven to be a
barrier as he tripped over the dog and injured his ankle. He is also a support as he is a possible
comfort to the client. Client has had difficulty with his phone/technology showing that the virtual
environment can be a barrier. Clients personal context of low socioeconomic status makes it
difficult for him to afford everything that he would like. One of clients biggest supports are his
willingness to participate and desire to improve.
A:

Client was independent in home strengthening exercise demonstration.

Client made good progress. He achieved 2/3 of his goals. He is taking steps towards increasing
his ability to initiate conversations with others, but goal was started late in therapy, and wasnt
met. Client would successfully meet goal with a few more weeks of therapy. He is planning on
doing volunteer hours at the VA and bowling more often. The barriers difficulty with technology,
socioeconomic status, distance from family, and presence of dog has proven to be a difficulty for
him to participate in his occupations. Clients willingness to participate and desire to improve
were beneficial in his improvement of occupational participation.

P: Client was encouraged to continue his core, hand, and arm strengthening exercises. He plans
to use dating websites to increase his participation in social interactions. He also plans to
participate in volunteer work with the VA when the finish his paperwork.
Colton Savage, OTS

April 23, 2016