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Skilled discharge summary of care and disposition of patient.

XX year old female patient, who at the initial start of occupational therapy services, required substantial assistance with all ADLS and functional mobility skills. Occupational therapy performed exercises, dynamic balance training, and ADL training with the patient and in addition, instructed patient and caregiver in daily home exercise program to work to increase functional abilities, ADL performance, and overall safety, reducing the risk for falls and injury. Patient has improved overall and her current level of care from caregivers is reduced compared to initial evaluation level. Now her caregiver understands more fully how to perform activities safely and more efficiently and ultimately her risk for falls and re-hospitalization has been mitigated.

Skilled Intervention section

Instructed patient in home exercise program, which included bilateral shoulder flexion, elbow flexion, wrist flexion and extension, and shoulder abduction. Instructed patient to perform exercises with good technique, making sure movements are slow and controlled through optimal range of motion as tolerated to maximize muscle involvement. In addition, instructed patient and caregiver in functional activities, including kitchen mobility, emphasized patient to be very careful when maneuvering around kitchen, carefully using cane to reach into cupboards and counter.

Objective Section

Objectively, patient requires stand by assistance to negotiate stairs in home to get to downstairs walk in shower. Patient is independent with upper body and lower body dressing. patient strength is 3+/5 in bilateral UE. Patient requires significant verbal cues and couching to safely negotiate stairs to enable bathing in downstairs walk-in shower. She requires stand by assistance for showering, needing cues to be able to perform task safely and effectively.

Assessment Secion

Patient presents with substantial limitations in ADL capacity, requiring substantial assistance to perform even basic ADLS. Based on the Barthel score patient is limited in all aspects of ADL performance, and in order to ensure safety, patient requires extensive assistance from caregivers. Patient and caregiver are limited in knowledge for how to perform all ADLS and functional tasks safely, effectively, and efficiently. Patient will benefit from occupational therapy to enhance patient’s ability to perform ADLS and functional tasks with good safety to reduce the risk for falls and other injury, ultimately reducing the risk for re–hospitalization and in addition increase patient’s level of functional independence, thereby reducing patient’ s reliance on caregivers to assist with all ADLS.

Patient presents with signifcant progress in ADL capacity, requiring decreasing assistance to perform ADLS. Patient is using her cane less and is demonstrating improved functional mobility and greater safety. Patient still presents as a falls risk and would benefit from continued occupational therapy to progress independence with showering and kitchen mobility to reach highest level of independence in the home, living alone.

Plan Section

Plan for patient with work with occupational therapy 2x/wk for 8 weeks with focus on increasing strength, balance, standing function, and instructing in a home exercise program and progressing that program each visit, in addition to concentrating on improving performance of ADLS in the mos safe, effective, and efficient manner to ultimately reduce chances of re-hospitalization.

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