Sample Report: Occupational Therapy Discharge Summary
History: This patient participated in the occupational therapy portion of the pain management center program for 24 days. He participated in a graduated activity program of upper extremity flexibility stretches, especially neck musculature and increasing upper extremity endurance, directed toward the following goals:
1. Patient will demonstrate understanding of home exercise program of bilateral upper extremity flexibility, stretching, and strengthening.
2. Patient will increase tolerance for bilateral upper extremity/shoulder activity, as evidenced by increased repetitions and increased resistance in exercises.
3. Patient will understand and utilize self-correcting techniques for appropriate head/neck posture with less guarding throughout the shoulders.
4. Patient will elucidate three changes he can make in his habits, which will improve his quality of life.
Goals Achieved: All of the above.
Physical Examination: Patient's full range of motion is essentially within normal limits, except at discharge the patient continues to experience slight pain with upward gaze in right trapezius, and head rotation continues -20 degrees of full 90 degrees, with pain to the right or left shoulder. Squat balance initially was poor and at discharge had improved to good. Initially the patient rated pain at 10/10 and at discharge 1/10 to occasionally 8/10.
Therapy Course: The patient attended scheduled therapy daily for either one hour or for two 30-minute sessions and came in extra time to work on his activity program. He gave fair effort during therapy. The patient was instructed in body mechanics and pacing, and demonstrated fair ability to carry over techniques learned in the treatment sessions. The patient was able to verbalize three changes he plans to make in his home and work routines to incorporate these principles. They are:
1. Relaxation techniques.
2. Exercise/stretching.
3. Pacing.
The patient's kyphosis remains severe with head thrust noted, but by discharge the patient is monitoring his posture better and recognizes the need to do chin tucks. The patient needed frequent reminders, plus demonstration, to stay focused and retain exercise techniques.
Therapy Results: At discharge, the patient showed the following improvements
GRIP STRENGTH
Initial Evaluation: Right 61 lbs. average, left 62 lbs. average
Discharge Evaluation: Right 67 lbs. average, left 59 lbs. average
BILATERAL COORDINATION
Initial Evaluation: Within functional limits
Discharge Evaluation: Within functional limits
ABLE TO LIFT
Initial Evaluation: 5 lbs. from knee height to 30" height
Discharge Evaluation: 10 lbs. from knee height to 30" height
ABLE TO CARRY
Initial Evaluation: 5 lbs. 400' with some shortness of breath
Discharge Evaluation: 10 lbs. 400' with appropriate pacing and had no problems
Disposition: The patient was given a written copy of his personal exercise and stretching routine and demonstrated activities correctly. The patient also requested two back support pillows to facilitate comfort in his seating.
The patient is discharged from the pain management center program at this time and is scheduled for followup in two months, not the traditional two-week followup, as the patient will be on vacation