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Artifact #1
Artifact #1
BACKGROUND INFORMATION
S: “I felt tricked last time when you asked what we all did last weekend, I thought about it all
O: Occupational Profile:
The client was evaluated on 1/25/2018 and 2/1/2018 at the University of Utah
outpatient setting. The assessments performed were an informal interview, the Canadian
The client is a 44-year-old male who suffered a traumatic brain injury (TBI) four years
ago from a downhill mountain bike racing accident which has affected his short-term memory.
The client is seeking services because his short-term memory impairment is continuing to affect
his daily occupations with his job performance when he is required to memorize sales scripts, in
social interactions when trying to recall names and conversations, forgetting where he placed
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his car keys and parked his car, when performing grooming tasks such as shaving only half of his
face, and burning food when he forgets that he was cooking dinner for his family.
His memory loss has also negatively affected his interpersonal relationships and career
resulting in a divorce, bankruptcy, job loss, and loss of friends. To just get by in his day-to-day
life, he remarked how people don’t realize how bad his memory is and how he often “fakes it”
Prior to his accident, he was a chef at Whole Foods who would frequently appear on
Channel 2 for cooking demos. He was an avid adventurist in outdoor sports and recreation,
particularly snowboarding and mountain biking. However, since his injury, he acquired
decreased balance and is not confident in his ability to make quick decisions and adjustments
that mountain biking requires. He now chooses to avoid all high impact sports because he
cannot afford another brain injury. However, he does choose to road bike to work on occasion.
Currently, he resides in Sandy, Utah with his fiancé, their combined four daughters, two
roommates, plus his two Great Danes for emotional support. His typical day includes waking up
to get ready for the day, taking his daughters to school and going to work. He reported he
cannot tell us what he does for work because he can’t remember. For him to recall what he
does for work, it requires him to go into work to read his own notes he left for himself the
The client has a good habit of taking notes at work to provide him with information
needed for the next day. He also takes notes digitally on his phone by entering in reminders and
alarms on his calendar for what he needs to accomplish each day. As a backup, his fiancé is also
included in all his iPhone calendar items, so she can also help remind him.
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While at work, the client interacts with the computer system, internet, email, sticky
notes for personal reminders, and phone while he works in a cubicle. When he arrives for work,
he begins his day by going through emails and then proceeds to call the clients. He attends to
important information for the clients in order to complete sales. He will initiate phone calls to
the clients, and has social interaction skills of approaching, speaking fluently, regulates self, and
thrown off track when an audience member asks a question. After answering the question, he
cannot remember where he left off. Although he reported that he performs in the top four of
his sales team, he is frustrated that he continually gets passed over for promotions by his
Following completing his work day, he picks up their daughters from school, then cooks
dinner with/without his fiancé. Finally, his evening routine includes picking out his clothes for
the next day and watching some shows before retiring to bed.
On the weekends, he enjoys attending parties with his fiancé; however, he reports he
cannot recall people he already met and their meaningful topics of conversation. His fiancé will
step in to explain he has a brain injury. He confided that it is embarrassing to him to both forget
people and have to inform them of his brain injury. Other weekend activities he enjoys are
hiking, spending time with family, and going to the movies—even though he cannot remember
them. His inability to recall movies bothers him because he cannot socially participate in these
conversations at work.
optimally perform at work to maintain his job, earn money for his family, and meet his own
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goals. He also wants to interact socially with coworkers, feel a part of the team, remember
names, faces, and topics of conversations. He also reported he desires to be able to function as
normally as possible in his life and not have to rely on faking anything. At work, he is fearful
about being perceived as incompetent. As a result, he is very private about his injury and he
does not want to tell human resources despite that his TBI affects his job performance.
OCCUPATIONAL ANALYSIS:
The client was evaluated at the University of Utah using both standardized and non-
activity.
Assessments Performed:
The informal interview given to the client addressed his typical day, allergies,
medications, home life, daily routines, personal goals and the Canadian Occupational
Performance Measure. Conclusions obtained from interviewing the client indicated his biggest
challenges are his visual and auditory short-term memory. These skill deficits are affecting his
ability to perform ADLs, complete work tasks, and social participation within his personal life.
interview that was used to address occupational performance problem areas in self-care,
productivity, and leisure. The top five occupational performance priorities were identified using
a rating system from 1 – 10 (least to most important). The results are listed below.
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10=performing
independently)
1. Work: remembering the client and 5 3
account details
2. Driving: remembering where he 6 5
parked his car and put his car keys
3. Self-care routines: finishing 7 6
activities completely
4. Work Presentations: effectively 2 2
presenting information w/o getting
distracted
5. Cooking: safely and w/o forgetting 6 7
and burning food
TOTAL 26/5=5.2 23/5=4.6
cooking task of making stove-top fudge. We observed him to learn where he may have
difficulties in various steps of completing the task, and difficulties in following directions,
staying on task, and how he handles distractions. We visually placed two ingredients in odd
places to determine if he could remember their location when the recipe required those exact
ingredients. Prior to beginning the cooking task, we asked how he thought he would perform,
he stated he thought he would do fine. During the cooking task, we implemented intended
distractions to see if and how he stayed on task. The cooking task proved was too simple for
him based on his former background as a chef. However, he did require 1 direct verbal cue to
return to the task. He also took 30 min to complete a 20 min recipe because he would stop
what he was doing to talk to us. When the two oddly placed ingredients came up in the recipe,
he was immediately able to find them. We inquired what strategy he used to recall where we
had placed them, he responded that he repeated in his mind, “microwave – pillow, microwave
– pillow”. He completed the cooking task and the recipe turned out perfectly.
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Finally, the client participated in a topographical activity throughout the building. This
task was chosen because he wants to improve remembering where he parks his car and puts his
car keys. In the task, we walked him through each floor of the building from the bottom to the
top with the client knowing his job was to get back to where we originally started. When at the
top floor, the therapist asked the client how he would get back down to his car, he reported
that normally he would just “walk out the front door and around the building till he found his
car rather than try to backtrack through the building.” The therapist provided 1 direct verbal
cue to start back down the stairs we had just come up. The client pointed out two landmarks he
recognized and did not make a single wrong turn. This task could have been too simple, or he
could have just guessed correctly. An additional challenge we added was when we asked if he
recalled our names; he replied he did not. We then graded this down and asked if he could
remember our faces. He hesitated and then stated he didn’t recognize us yet and added, “I
would not recognize you if out in public unless you told me who you were, that is another
problem I have.”
A: INTERPRETATION:
The client is very high functioning despite his TBI. He is also friendly and engaged in the
therapy process. He has already implemented effective compensatory strategies using his
iPhone calendar and alarm system to remind him of important tasks throughout the day. He
was able to cook well and utilized an alarm to make sure he performed each task with exact
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problems with attending as evidenced from the cooking task. Although he was able to recall
where the ingredients were placed, it was likely due to the simplicity of scenario. At his first
interview he was unable to recall information given at the beginning of the session when asked
again for it at the end of the session. When scenarios become more complex, he displays
limitations with recall. Areas of need for intervention are needed to implement further improve
cognitive strategies for attention and memory to improve his occupational performance.
Current supports to the client is his fiancé, daughters, two Great Danes, and boss that
works with his memory impairment limitations. Current hindrances to his occupational
performance is his lack of visual and auditory short-term memory and limited attention span.
Also, he does not have insurance, is limited financially, and cannot afford professional services.
While his memory has improved from 20 minutes to 10 hours, it is highly unlikely his memory
The client’s top areas of need center around improving his strategies to strengthen his
attention and memory ability within the context of work, socializing with coworkers, cooking at
home, completing self-care tasks, and navigating within the community. Priorities derived from
the COPM are to improve in work performance and remembering where he parks his car and
Organizing Model:
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The Person Environment Occupation (PEO) model will be implemented to help increase
the client’s satisfaction by improving the congruence of his occupational performance between
himself, his occupations, and his environments to provide support with visual cues and increase
beliefs about [his] environment and occupations [that] influence subsequent occupational
Strong, Stewart, Rigby, & Letts, 1996).” This postulate is valuable because the client has verbally
expressed a belief that he cannot do certain things and that “those days are past”. Because we
know how he perceives his abilities, we can provide education with applicable strategies to
strengthen his environment by providing important visual supports within his environment and
regimens to cue him to use his current amount of memory that will improve his occupational
performance.
The second postulate applicable to our client is “the environment is dynamic and can
have an enabling or constraining effect on occupational performance (Law et al., 1996).” This
postulate is valued because addressing needed environmental changes can help to support our
client without expecting internal change of the client. Furthermore, we realize that attempting
to change the person will take more take time and may prove unsuccessful give our time period
that is makes the most sense to set the client up for success with as many environmental and
occupations.
Complementary Model:
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The Dynamic Interaction Model (DIM) focuses on internal and external factors of those
with cognitive dysfunction that possess the potential to improve by changing the demands of
the activity, the environment, and application of strategies. This model addresses dynamic
interactions between the person, activity, and the environment. Important postulates we will
center our intervention on are “change can occur as cues, various teaching strategies, and a
reduction of demands are used by the occupational therapist (Toglia, 2011).” This approach
stresses the importance for us as his occupational therapists to provide the best strategies to
create a just right challenge to help him gain additional skills and confidence despite his
demands of the activity, the environment, application of strategies, and self-awareness (Toglia,
2011).” As we work to find ways to make adaptations to his environment and improve his
environmental and cognitive strategies, this will help to make the client be more successful in
Doig, Kuipers, Prescott, Cornwell & Fleming (2014) examined how goal planning and the
traumatic brain injury. Researchers found that engaging a client’s participation in occupation-
based and goal-directed rehabilitation activities appeared to foster increased personal growth
and improved self-awareness related to their injury. Although he does not have problems with
self-awareness, we can utilize goal planning and the principles of self-awareness to educate our
client on deciphering what visual or cognitive strategies he can implement in difficult areas of
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Considering this research outcome, we aimed to create two tasks our client reported
difficulty with, burning food and forgetting where he parked his car and placed his car keys. The
intervention included similar challenges to see how self-aware the client was and what
strategies he implemented to be successful or not in the tasks. First, we created a cooking task
where two ingredients were oddly placed within the client’s view to test his memory when he
got to those ingredients of the recipe. He successfully completed the task, and remarked that
during the cooking task, he continually repeated in his mind, “microwave, pillow, microwave,
Based on the client’s results from his standardized and non-standardized assessments
and concerns expressed by the client, including the observation obtained during the cooking
task and topographical activity, intervention goals will focus on improving attention and
memory strategies to work tasks, social situations, cooking tasks, and ADLs participation
Expected Frequency & Duration of Treatment: It is recommended that the client receive skilled
occupational therapy services for 1 hour a day, 1x per week for 6 total sessions.
Location of Intervention: The University of Utah--520 Wakara Way, Salt Lake City, UT
Anticipation D/C Environment: The client is currently living at home and will be discharged to
home.
GOALS
LTG #1: Within six sessions, the client will independently perform work tasks utilizing memory
STG 2: Within four sessions, the client will independently utilize memory strategies during social
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STG 1: Within two sessions, the client will utilize memory strategies with minimal verbal cues
LTG #2: Within six sessions, the client will utilize process skills with adaptive strategies to
complete everyday tasks (such as cooking, completing ADL’s, answering email etc.)
STG 2: In four sessions, the client will utilize strategies with minimum verbal cues to sustain
attention to everyday tasks (such as answering email at work, cooking, cleaning etc.)
STG 1: In two sessions, the client will verbalize when the pace of an activity such as cooking is
ineffective and implement strategies to improve pacing with moderate verbal cues. Goal
discontinued.
New goal STG 1: In two sessions, the client will attend to therapy tasks when distractions are
Date: 2/1/2018
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References
Doig, E., Kuipers, P., Prescott, S., Cornwell, P., & Flaming, J. (2014). Development of self-
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-
Toglia, Joan (2011). The dynamical interactional model of cognition in cognitive rehabilitation.
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