Date of Assessment: 01/31/2020

Name: Client

Diagnosis: Traumatic Brain Injury

Occupational Therapy Initial Evaluation

S: “My brain is alot better now.”

O: Client was seen 1/24/2020 and 1/31/2020 for comprehensive occupational therapy evaluation,
including an occupational profile interview, an observation of occupational performance, and
administration of the Canadian Occupational Performance Measure (COPM), Memory
Orientation and Concentration Test (Short Blessed Test), and Mortera-Cognitive Screening
Measure (M-CSM).

Occupational Profile:

Client is a 56-year-old single male who suffered a traumatic brain injury (TBI) 4 years ago, after
falling down his indoor stairs at his mother’s home while intoxicated. After his injury, he was
hospitalized and was in a coma for 2 weeks. After he woke from his coma, he received inpatient
rehabilitation services for 1 week at the University of Utah, was moved to Promise Hospital and
stayed for 2 weeks, then went to St. Marks Hospital for 2 weeks, and a care facility for 2 weeks
before returning to live at his mother’s home. He continued to receive outpatient OT services for
TBI symptoms for a year after returning home. He currently receives no medical or rehabilitation
treatment, outside his primary care physician. He takes medication twice daily for seizures and if
taken irregularly he is prone to seizures. The last seizure he experienced was over a year ago.
Side effects of the seizure medication are dizziness, difficulty with balance, hand trembling, and
difficulty with depth perception which impact daily life. Client also takes fluoxetine daily, an
selective serotonin reuptake inhibitor (SSRI) commonly prescribed for symptoms of depression
and anxiety. He reports sustaining a R UE nerve injury while playing highschool football, which
required surgery. Client reports that is R UE is WFL, with AROM of 30 degrees of shoulder
abduction and 45 degrees of shoulder extension.

Client reports living with his 95 year old mother and their pet cat, in his mother’s home near
Coalville, Utah. On a typical day after waking in the morning around 7 am, he makes coffee,
retrieves the newspaper, and makes himself a microwave breakfast. Meals are typically prepared
by his mother but he independently prepares microwaved meals. At meals he takes his
medications, which require minimal verbal prompting from his mother but he relies on his
mother to prepare his pill box. Client is independent with his ADLs. He stated that he is often
bored and spends the majority of his day watching t.v., mostly sports, and reading. Occasionally
he will go on a walk, if he needs to mail a letter at the post office. He does not drive, although he
would like to, and his sister, whom lives nearby in Coalville, assists in transporting him to
appointments and the grocery store. He has taken the bus with assistance on several occasions,
but does not have a goal of becoming independent riding the bus. At home, he assists with snow
management outdoors, sweeping the kitchen, and cleaning the cat box. His mother performs all
other household management tasks, which his sister reports are due to a lack of motivation on the
client’s part.

Client shared that he goes to lunch with his friend John on occasion, spends time with his
mother, and sister. Before his injury, he liked to recreationally golf, fish, and hunt but has not
done those activities in years. Client said that he likes to read and watch t.v. After highschool
graduation, client worked as a tile setter. He would like to return to work and explained that he
has an interest in becoming a hunting guide. He is currently working with the Department of
Workforce Services to find employment.

Occupational Performance Assessment:

Memory Orientation and Concentration Test (Short Blessed Test): Client scored a 6/28
which indicates a normal-minimum impairment. On item 5, the client was prompted to say the
months of the year in reverse order. Client was unable to list the month after December. Client
received an indirect verbal prompt, “In what month is there Thanksgiving?” and responded with,
“February” then said, “I don’t know, I was never too good in school. Especially with reading, I
had a tutor for reading when I was in elementary school.” Client was able to recall ⅘ sections of
an address that he was asked to remember that he learned 2 minutes prior.

Mortera-Cognitive Screening Measure (M-CSM): Scored results indicate problems with

sustained attention and awareness of disability and a potential problem with visual attention-
scanning and judgment relative to safety. M-CSM defines a deficit in sustained attention as,
“marked distractibility during a task and the inability to engage in activities that may require
focus for 15 minutes or more.” and awareness of disability as, “a cognitive process involving the
ability to appreciate the extent of one’s physical and cognitive abilities and deficits and to
identify the effects of these deficits on the performance of functional tasks.”
During the assessment, client was observed using his non-dominant left hand and required
several attempts to put the can opener on both the soup and tuna fish can. Client’s hands shook
during fine motor tasks. He required direct verbal cues with gestures for positioning the can
opener on the soup can, gathering ingredients for making the sandwich, and to combine the tuna
and mayo before spreading on the bread. After finishing warming up the soup of the stove top
and turning off the burner he required an indirect verbal cue to pour soup into a bowl. He
required mod-min verbal cues for task sequencing throughout the assessment and was verbally
redirected multiple times to attend to a task instead of talking.

Canadian Occupational Performance Measure (COPM): An informal interview was

performed using the COPM to identify areas of occupation the client would like to address in
therapy. Client identified goals of wanting to return to driving, return to golfing, and be hired as
a hunting guide. His sister stated that returning to driving isn’t a family goal and would not be a
safe activity for the client.

Uno Card Game:

Client was given the new, plastic-wrapped cards and asked to unwrap and shuffle them. Client
independently removed the plastic wrap and attempted to shuffle cards, by using his L & R
thumbs to pick up the card corners. Client connected the edges of the cards during shuffling but
did not complete the task. Client was asked to deal 7 cards to each player. He stated that he had
never played Uno before and was told the rules of the game. He required indirect verbal
prompting to count cards after not dealing cards to himself and dealing 6 cards to each player.
Client required indirect verbal cues on his turn, the therapist asking, “Do you have any 5’s? Do
you any yellows?” When given no verbal prompts in the second round of the game, client placed
the incorrect card (a yellow 3 on a green 6). On several of his turns, client picked up a card from
the deck when he could of played a card in his hand.

A:

Client is an optimistic and personable individual, who is motivated to participate in treatment. He

is open to trying new strategies and has goals to improve his quality of life. He is well-supported
by his mother and sister, whom assist him in performing daily IADLs. He has stable housing
with his mother and is responsible for several household tasks. He is independent in his ADLs.
He demonstrates safety awareness during tasks. Client has an intact long term memory, being
able to remember details from his past that occured before his accident. Assessments indicate a
lack of insight into his disability and the impact it has on his present and future. Observations
indicate deficits in sustained attention, cognitive processing, task initiation, task termination, and
working memory. Client is able to attend selectively and multi-task (speaking and completing a
task simultaneously). Client’s sister reports that the client and his mother have a “drinking
 problem”, which may affect the client’s health and safety. Client’s mother performs IADL tasks
for the client, which he is physically capable of performing with verbal cues.

P: Client will be treated for 60 minute sessions 1x/week for 6 weeks to address deficits in
insight, working memory, sustained attention, task initiation, and task completion that interfere
with occupational performance in IADLs. Skilled OT services are required for appropriate
grading of activities that will address performance deficits. Client’s complex condition requires
advanced clinical judgement to adjust the presentation of activities that will properly challenge
him while also teach him to generalize strategies beyond the treatment session.

Goals

LTG: In 5 weeks, client will complete a four-step cooking task with min VC.

STG: In 3 weeks, client will complete a two-step cleaning routine with min VC.

STG: In 2 weeks, client initiate steps in a simple cooking task with mod VC.

LTG: In 5 weeks, client will use a daily schedule with min indirect VC to complete IADLs
assigned per caregiver.

STG: In 3 weeks, client will complete one 2-step IADL task after checking his daily schedule
with min VC.

STG: In 2 weeks, client will check his daily schedule in the morning, with no more than 2 direct
VC, per caregiver report.

Goal 1: In 5 weeks, client will use a daily schedule with min VC to complete IADLs assigned
per caregiver.
**HINTs:each column should have 3-5 bulleted measures.
***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2”
column (Baseline performance) and then fill in the rest of the columns in between.

-2 -1 0 +1 +2
Distal ( (Baseline) (Goal)
Outcome
(LTG): Much Less Less Expected Level Better Much Better
 Using daily
schedule for Dependent on Max VC to Use daily schedule
IADLs caregiver for perform with min VC to
IADL IADLs complete IADLs
completion

Proximal Outcomes (STGs) Measurement Criteria Baseline Baseline

1) 1) Level of assistance to 1) Requires max VC to use compensatory strategies.

Compensatory initiate use. 2) Uses compensatory strategies 0% of the time.
strategy use 2) % of times used during
task.

2) Initiation 1) Level of assistance 1) Requires max indirect VC and min direct VC.
2) Does not use any compensatory strategies.
2) # of times used
compensatory strategy

In 5 weeks, client will complete a four-step cooking task with min VC.
**HINTs:each column should have 3-5 bulleted measures.
***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2”
column (Baseline performance) and then fill in the rest of the columns in between.

-2 -1 0 +1 +2
Distal ( (Baseline) (Goal)
Outcome
(LTG): Much Less Less Expected Level Better Much Better

(Occupation/ Dependent on Max VC to Min VC to complete

Target caregiver for complete four-step cooking
Behavior) food four-step task.
preparation. cooking
 Four-step task.
cooking task

Proximal Outcomes (STGs) Measurement Criteria Baseline

1) 1) Level of assistance to 1) Requires max VC to use compensatory strategies.

Compensatory initiate use. 2) Uses compensatory strategies 20% of the time.
strategy use 2) % of times used during
task.

2) Initiation 1) Level of assistance 1) Requires max indirect VC and min direct VC.
2) # of times used 2) Does not use any compensatory strategies.
compensatory strategy

3) Attention 1) Level of assistance 1) Requires min direct VC with gesturing.

2) Length of time 2) Becomes distracted after approximately 1-2
minutes.

Client is an excellent candidate for progress with OT services. Thank you for the opportunity to
assist him in returning to independence in his occupations.

Research:

Dynamic Interaction Model of Cognition (DIM): In a study conducted by Ownsworth T,

Fleming J, Desbois J, et al (2006), a systematic feedback approach was used to encourage
insight, error detection, and strategy development. DIM states that cognition is modifiable and
is affected by continuous learning. Self-awareness, self-monitoring, and effective strategy use
can be improved when the “just right” challenge is provided. During treatment, client will
participate in self-reflection before and after a task to improve self-awareness.

CO-OP: In a pilot study conducted by Dawson, D., Gaya, A., et al (2009), the CO-OP model
was used as an intervention approach to address adults with executive dysfunction following
traumatic brain injury. Participants used a meta-cognitive problem-solving strategy to perform
daily occupations. An objective of CO-OP is generalization of skills and strategies into everyday
life, just as participants were encouraged to do.

Signature

Raquel Perea, OTS

References
 Ownsworth T, Fleming J, Desbois J, et al: A meta-cognitive contextual
intervention to enhance error awareness and functional outcome following traumatic brain
injury: a single-case experimental design, J Clin Exp Neuropsychol 12(1):54-63, 2006.

Dawson, D., Gaya, A., Levine, B., et al. (2009). Using the cognitive orientation to
occupation performance (CO-OP) with adults with executive dysfunction following traumatic
brain injury. Can J Occup Ther, 76 (2). Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/19456090