Melissa Weddington

Community client discharge summary

Occupational Therapy Discontinuation Report
Date of Report: 4-19-14
Name: Community Client
Age: 41
Date of Initial Referral: 1-17-14
Primary intervention diagnosis concern: Strength, AROM and motor control of R UE secondary
to L CVA
Precautions/contraindications: N/A
Reason for referral to OT: Decreased participation in occupations secondary to R UE strength,
AROM and motor control.
Reason for OT discontinuation: Client has met occupational goals
Therapist: Melissa Weddington MOTS
Description of OT interventions: Client was seen in a variety of settings including the Life
Skills Clinic, her home and out in the community to address occupational performance in areas
she deemed as meaningful. Client was seen for nine one hour sessions. Therapy began in January
and ended on April 11, 2014. Interventions provided to the client included introduction of a HEP
to strengthen and improve ROM of R UE, education on proper positioning of UE and adaptive
strategies. Therapeutic activities were used to achieve her occupational goals included cooking,
using utensils, using a hammer and typing.
Brief summary of progress towards goals:
Client met one of her two short term goals and is making progress towards the second goal. She
has met goal number one and is now able to type an email with proper positioning with modified
independence. She is making progress towards her second goal of reporting an increase in her
performance and satisfaction on the COPM of 2 or more points. Client met half of this goal by
reporting an increase in satisfaction of 2.2 points. She did not meet the second part of the goal
because she reported improved overall performance of 1.8 points. Her increase in performance
score still indicates some perceived progress towards her goals, although it did not meet her
initial goal of improving by 2 points.
Occupational Therapy outcomes:
Initial performance in areas of occupation:
Client initially typed emails slowly using elbow and shoulder movements to compensate
for finger dexterity and decreased AROM in her wrist. She used similar compensatory strategies
when cooking, brushing her teeth and cutting with a knife. Client had only slight abduction and
adduction in her fingers which made typing slow and cause her difficulties when operating the
computer mouse. When standing to do a task Client put her weight through her L LE and leaned
to the left and required mod verbal cueing to put weight through B LE.
Initial assessment information is listed in a chart form in the following section to allow for
comparison of pre-post testing.
Current performance in areas of occupation:

Client has made significant improvement in her occupational performance. Client can now
independently position herself at the computer to prevent compensatory movements and promote
optimal typing speed. Client now is able to better reach all keys on the key board and operate a
mouse due to increased AROM of the finger abductors and adductors. Client has experienced an
increase her ability to use a knife, brush her teeth and cook due to increase strength and AROM
of her R UE. Client now requires only one verbal cue per session to put weight through B LE.
She recently got a part time job in public relations.

Movement

AROM table of pre and post testing

Clients initial
Normal limits
Clients final AROM Difference
AROM
between initial
and final
45
80 Degrees
70
+25
25
70 Degrees
50
+25
20
30 Degrees
20
0
WNL
20 Degrees
WNL
15
50 Degrees
25
+10
WNL
80 Degrees
WNL
70
90 Degrees
65
-5

Wrist flexion
Wrist extension
Ulnar Deviation
Radial Deviation
Thumb MP flexion
Thumb IP flexion
MP flexion/extension
(2)
MP flexion/extension 55
90 Degrees
75
+20
(3)
MP flexion/extension 65
90 Degrees
75
+10
(4)
MP flexion/extension 75
90 Degrees
80
+5
(5)
PIP flexion/extension 105
110 Degrees
WNL
(2)
PIP flexion/extension 105
110 Degrees
WNL
(3)
PIP flexion/extension 110
110 Degrees
WNL
(4)
PIP flexion/extension 105
110 Degrees
WNL
(5)
DIP flexion/extension 45
90 Degrees
60
+15
(2)
DIP flexion/extension 45
90 Degrees
60
+15
(3)
DIP flexion/extension Error
Error
Digits 4-5
Summary: Client made significant increases in AROM for wrist extension, flexion, thum MP
flexion, MP flexion/extension of digits 3 and 4, and DIP flexion/extension of digits 2-3.

Canadian Occupational Performance Measure (COPM) is a semi-structured interview that acts

clients about areas of occupational difficulty and then has the client rank them in order of
importance. The client rates selected occupations on performance and satisfaction.

COPM: performance: 1-low 10 high

satisfaction 1-low 10-high
Occupational performance
Performance
Performance
Satisfaction
Satisfaction
concern
score pre
score post
score pre
score post
1. Typing with R hand
6
7
6
8
2. Brushing teeth with R 3
6
3
6
hand
3. Keeping balanced
6
8
6
7
during active
recreation
4. Using a knife to cut
5
7
5
7
with R hand
5. Fastening jewelry
3
5
1
5
with R hand
Total scores
23/5= 4.6
32/5=6.4
21/5=4.2
32/5= 6.2
COPM scores indicate an improvement of 1.8 points in satisfaction and 2.2 points on
performance.

Contextual aspects related to discontinuation:

The clients personal qualities have contributed to her progress. She is highly motivated and
independent. She has been zealous about completing the HEP and continues to find new ways to
challenge herself. Her temporal context has recently changed because she has begun a new job in
public relations. She has been not been working for over a year and is excited to take on the next
challenge. Client has a sister that lives nearby and a mother and another sister from out of state
that visit regularly. Client has found social and emotional support through her newly created blog
and her volunteer work with the National Stroke Association. Clients physical environment of
her home is a support for her. She now positions her computer in a way that promotes optimal
body mechanics and prevents compensatory movements.
Discontinuation recommendations:
Upon discharge client was provided with a binder of resources. She was instructed to continue
using her HEP program and will grade up exercises as needed using suggestions given to her in
the binder. Client will continue to utilize strategies used in therapy to help her to better use her R
UE. Client has adapted her physical context by moving her computer further back on the table to
increase her performance in typing. In addition to information about her HEP client was
provided with was provided with handouts outlining strategies we used in therapy, resources for
improving hand function and community classes for social media.

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