What the OT Progress Report Generator actually produces

**Patient:** Marcus T., 58M, R CVA with L hemiplegia, dx 6 weeks prior to report period. Referred by Dr. Patel (neurology). Treated at Riverside Rehab Clinic, 3x/week outpatient. **Report Period:** April 1 – June 30, 2025. **Summary:** Consistent engagement with OT interventions. Significant functional gains in UE motor control and ADL independence. Patient demonstrates strong motivation and carryover of strategies. Continues to benefit from skilled OT intervention.

**Goal Progress:** Goal 1 (UE dressing independence): Progressed from max assist to min assist for shirt/pants. Current performance = 75% toward independence. Goal 2 (L hand grip): Improved from 8 lbs to 14 lbs (70% toward 20 lb target). Goal 3 (meal prep safety): Baseline = unable to initiate; current = completes cold meals (sandwiches, cereal prep) with supervision and safety checks present. **Functional Trends:** L shoulder active ROM improved ~20° (flexion and abduction), reducing compensatory patterns. Drop-arm incidents during ADL reduced by ~60%. Standing tolerance at kitchen counter increased from 1-2 min to 4-5 min, enabling longer meal prep and grooming tasks. Fatigue remains a limiting factor in morning routines (upper-extremity endurance < lower-extremity), restricting ADL sequencing in early AM. **Data Interpretation:** Consistent improvement trajectory suggests motor recovery progressing and neuroplastic changes supporting functional re-learning. Rate of progress is appropriate for 12-16 weeks post-CVA. Continued skilled intervention justified.

**Continue OT:** 3x/week x 8 weeks (through August 2025) to sustain gains and progress toward independence in meal prep and community ambulation. **Equipment Trial:** Introduce buttonhook, plate guard (unilateral), and reacher during next 2 sessions to assess impact on independence and safety during meal prep. **New Interventions:** Add structured energy conservation training (activity pacing, task breakdown) for morning ADL routine to address fatigue pattern. Incorporate standing meal prep simulation to build standing endurance and functional carryover. **Home Safety:** Recommend OT home visit to assess grab bar placement, kitchen layout, and bedroom/bathroom accessibility for safe discharge planning (estimate 6-8 weeks). Coordinate with PT for fall risk assessment and caregiver training. **Reassessment:** Formal reassessment at 8-week mark (end of August) to determine need for continued skilled OT vs. discharge to home program and community resources.