Sample Name: Occupational Therapy Discharge Summary
Description: Occupational therapy discharge summary. Traumatic brain injury, cervical musculoskeletal strain.
(Medical Transcription Sample Report)
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.
Keywords: discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,