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Occupational Therapy Discharge Summary

DIAGNOSES: Traumatic brain injury, cervical musculoskeletal strain.

DISCHARGE SUMMARY: The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.

RECOMMENDATIONS: Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.

Thank you for this referral.

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