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Danielle Oberg

OC TH 6220
Community Client
Occupational Therapy Discontinuation Report
Date of report: 04/25/2014
Name: C.J.
Date of birth &/or age: 70
Date of initial referral: 1/16/2014
Primary intervention diagnosis/concern: Right CVA
Secondary diagnosis/concern: Left inattention, Left hemiplegia
Precautions/contraindications: None
Reason for referral to OT: Community Client
Reason for OT discontinuation: Completion of course
Therapist: Danielle Oberg, OTS; Cambry Kaylor, OTS
Description of OT Intervention:
Client was seen for treatment in his home x60 minute sessions 1-2x/month x3 months for
5 total visits. Interventions addressed bed mobility, left inattention and high tone in the
LUE. 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. Interventions were based on performance concerns
identified on the COPM. Therapy students were accompanied by Kasey Mitchell, OTR/L
for the final session. OTR educated client on strategies to improve clients attention to
the left and decrease anxiety.
Brief summary of progress towards goals:
Client showed improvement towards goals in the first three sessions. Client met first LTG
and demonstrated appropriate use of AE and techniques for bed mobility with modified
independence. Client demonstrated a decrease in functional mobility over the course of
five sessions and refused to use the walker for ambulation or work towards standing
grooming task as previously identified. Secondary to clients refusals, goals were
adjusted to address high tone and left inattention to complete meal prep tasks. Up to the
fourth session, the client demonstrated increased PROM/AROM in LUE and hand;
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 that would help to decrease tone. Client demonstrated increased attention to the
left with min verbal cueing over the course of therapy.
Occupational therapy outcomes:
Initial performance in areas of occupation:
Client provided feedback when The Canadian Occupational Performance Measure
(COPM) was administered during initial evaluation. Results were utilized to establish
client-centered goals and plan intervention. Throughout the course of treatment, goals
were revised based on clients performance. Clients goals were focused on occupationbased goals related to left-inattention and incorporation of the left UE specifically. The

Danielle Oberg
OC TH 6220
Community Client
COPM was not re-administered during final session. Initial functional evaluation showed
client was dependent on bed mobility, required moderate direct verbal cueing to attend to
the left UE and environment, and mod assist in meal prep activities.
Current level of performance in areas of occupation:
Following final treatment, client is able to turn in bed with modified independence
utilizing strategies and AE as taught by therapy students. Client still requires moderate
direct verbal cueing and verbal encouragement from spouse to attend to the left. Client
experiences increased anxiety during mobility and meal prep secondary to left
inattention. Client requires min assist in meal prep activities due to high tone and poor
motor control in the LUE.
Contextual aspects related to discontinuation:
Client will continue to live with his wife in accessible apartment. Wife is educated on
strategies to improve left attention, including bringing his attention to the left. Wife was
also educated on UE ROM stretches and exercises to assist in improving left UE
function. Client and wife are also educated on the importance of repetition and use of
bimanual tasks and incorporation of left UE in daily tasks.
Discontinuation recommendation:
Recommendations for discharge include client to continue seeing outpatient OT and PT
services based on current referral. Client to continue incorporating LUE in daily
activities and wearing L hand splint to improve hand extension and tone in LUE. Wife to
provide verbal cueing as needed to facilitate left attention to self and environment. It is
recommended client attend wellness clinic once a week to address fatigue. Client to see
physician for Botox injections in order to decrease tone.