Date of Assessment: 3/30/21

Name: Isabel Austin

Diagnosis: Right hemisphere traumatic brain injury

S: The client was pleasant and agreeable during evaluation. When informed that she almost fell
in her chair during occupational observation, she responded “I wouldn’t fall!”

O: Client was seen 3/42/21 and 3/30/21 for comprehensive occupational therapy evaluation,
including an occupational profile interview, COPM, an observation of occupational
performance, as well as the Fugl-Meyer and PASS assessments.

Occupational Profile:

The client is a 30-year-old female with a right hemisphere traumatic brain injury (TBI) that is the
result of being a passenger in a car accident that occurred 4 weeks ago. The client has been
married for 2 years and her spouse is a firefighter that works 24 hours on, 48 hours off. They
have 4 kids but only the client’s biological 6-year-old son lives with them. Prior to the accident,
she worked full-time as a Human Resource representative for a large tech company and
volunteered most Sundays at a local SNF with her therapy dog. Other aspects of her everyday
life before her accident include morning routine which involves dressing for work and
showering, household maintenance such as cleaning and laundry, helping her son with
homework, caring for her pet, paying bills, grocery shopping, mountain biking, hiking with her
dog, camping in a tent, and attending a weekly spiritual group. She is highly motivated to return
to work in a few months.

Canadian Occupational Performance Measure (COPM) Chart:

Occupational Performance Problems Performance Satisfaction

Return to work 3 2
Medication 8 8
Shower/dress 7 5
Time with dog 1 1
Hot tub 1 1
TOTAL 20 17

The COPM is a client centered, occupation based, individualized measure that is designed to
detect change in a client’s self-perception of occupational performance before therapy and
after. It is used as an outcome measure but also provides information for goal writing at the
beginning of therapy. It is administered via interview. The left column lists the occupation
priorities of the client and the right two columns reflect performance and satisfaction. The
scores are on a 0-10 scale.
Occupational Performance Assessment: The client participated in a meal preparation activity in
her home while seated in her w/c that consisted of setting up the task by finding and gathering
ingredients, cutting with a knife, and assembling the meal. The client required continuous
verbal non-directive and verbal directive cues throughout the activity and consistently needed
to be re-directed to the task. On several occasions, she made unrelated comments and asked
unrelated questions during the activity, such as asking if she should feed her dog a cheese
cracker. She frequently began to engage with her dog or became focused on unrelated objects
in the room such as her string lights or food that she was not asked to retrieve. She required >3
cues to turn on the lights in the room and switched the incorrect lights on twice. On 2 occasions
the client leaned forward in her w/c, almost falling. She moved throughout the kitchen quickly
and without hesitation while touching many items and opening many cabinets. To open the box
of crackers and a cylinder-shaped container, she IND incorporated her L hand to stabilize the
object while the R hand opened the lid. When washing her hands, she IND used her RUE to lift
her LUE into the sink to wash it. She used her teeth to open bagged items. She required cues to
open and close the left door of the fridge. She propelled herself in her w/c IND using her R side.

PASS Chart:

Task IND mean score Safety Score Adequacy Score

3: no assists given
2: no level 7-9 assist
(physical guidance, physical
support, total assist),
occasional 1-6 support
(verbal supportive, verbal
directive, gestures, task
rearrangement, and
demonstration)
1: no level 9 assist, or
occasional level 7 and 8
assist, or continuous level 1-
6 assist
1: no level 9 assist, or
occasional level 7/8 assist, or
continuous level 1-6 assist
0: level 9 assist, or
continuous level 7/8 assist,
or unable to initiate,
continue, or complete sub
task
Shopping 2 3
Medication 2.33
Telephone Use 2.86
Bingo 1.5
Dressing 2.55
3: safe practices 3: optimal performance,
observed subtasks performed with
2: minor risks to safety precision and economy
observed and no 2: acceptable performance,
assistance provided subtasks generally
1: risks to safety performed with precision
observed and assistance and economy, occasional
given to prevent lack of efficiency,
potential harm extraneous action, no
0: risks to safety severe missing steps
to the point task was 1: marginal performance,
stopped or taken over to subtasks generally
prevent harm performed with lack of
precision and economy,
extraneous actions, steps
missing
0: unacceptable
performance, subtasks
performed with lack of
precision and economy,
task progress unattainable
2
2 2
2
1
2 1
The PASS is a dynamic assessment that examines both motor and process skills during
occupational participation of various tasks. Each score is on a 0-3 scale and the meaning of the
scores for each category is listed in the chart. During shopping, bingo, and telephone use task,
the client occasionally made unrelated comments or questions that resulted in her missing
information or requiring verbal directive cues to redirect her to the task. She was cued to
incorporate her LUE when opening a child proof pill bottle and eventually required physical
support to stabilize the bottle. Once the bottle was open, she ate a fake pill although the OT
told her not to which impacted her safety score. She required multiple verbal cues for the day
of the week. When counting money to pay for groceries, she required a gestural cue to notice
the dollar bills to her L side. She knew the change she was given was wrong but informed the
OT That she didn’t mind. When dressing, the client had difficulty dressing her LUE after dressing
her RUE and was cued to start with her LUE dressed first. She was cued to incorporate her LUE
when buttoning. Donning socks took extra time but the client did it IND and donning shoes
required continuous verbal, gestural, task rearrangement, and demonstration cues to show her
how to use her LUE to stabilize laces while tying with RUE. While obtaining the number off an
Rx bottle for the telephone use task, the client needed verbal cueing to locate the number.
During bingo, the client required consistent cueing to listen to the caller. She did not call out
bingo when she had it and did not notice bingo when given a verbal cue to look.

Fugl-Meyer (FMA) Chart:

FMA-UE (A-D) Score FMA-UE (H-J) Score

A. Upper Extremity 16/36 H. Sensation 12/12
B. Wrist 2/10 I. Passive Joint Motion 24/24
C. Hand 5/14 J. Joint Pain 24/24
D. Coordination/Speed 3/6
TOTAL A-D (motor function) 26/66

The Fulg-Meyer assessment of the upper extremity assesses sensorimotor function. The motor
function aspect of the FMA-UE is scored by recording 0 (none), 1 (partial), or 2 (full). Results of
this assessment indicate that the client demonstrates normal light touch and proprioceptive
sensation, normal passive joint motion and no joint pain during passive range of motion. The
results indicate impaired motor function. The client demonstrates partial movement of each
action of the shoulder, no elbow extension, and full elbow flexion. The client was unable to
pronate/supinate her forearm with a straight elbow but could partially pronate/supinate with a
bent elbow. The client has hyperactive reflexes of the LUE. The client is able to extend her wrist
15 degrees while her elbow is at 90 degrees but is unable to maintain extension with resistance.
She is unable to extend her wrist 15 degrees when the elbow is straight. Partial (limited active
range of motion) repetition of this movement is possible when elbow is at 90 but no repetition
is possible when elbow is straight. No circumduction of the wrist occurred. She has full mass
flexion of the fingers and partial mass extension. The client is unable to perform a hook grasp,
pincer grasp, or spherical grasp and has partial (cannot perform when object is tugged) thumb
adduction and cylinder grasp. Her coordination/speed score indicate that there is a slight
tremor, no dysmetria, and that the affected UE completed the subtest >6 seconds slower than
unaffected UE.

A: Interpretation: Based on information gathered from interview, observational performance,

and assessments, the client’s performance is hindered by a variety of personal, occupational,
and contextual barriers. Her limited motor control in her LUE, as shown in the FMA-UE, inhibits
her ability to incorporate her LUE into her occupations which was demonstrated when she was
unable to stabilize the pill bottle to open it during the PASS. The available movement she does
have in her LUE can be improved with repetition and use during functional tasks. She
demonstrated L body neglect and often forgot to use her arm which was shown when she
required cues to incorporate when buttoning a shirt. This should be addressed to avoid non-
use. The client has also shown signs of L side neglect when needing cues to attend to her L side
during meal preparation and shopping. She demonstrated impulsivity when eating a fake pill,
when leaning in her w/c and almost falling, as well as during dressing when standing to
don/doff pants and losing her balance which indicates that she lacks safety awareness. Her
husband works 48 hour shifts and will be unable to be with her and her son which contributes
to safety risk and could impact the safety of their child as well. The client has consistent
difficulty attending to tasks which was apparent during the PASS and occupational performance
assessment. She is easily distracted by her environment and tends to get off topic by asking
unrelated questions and telling unrelated stories which makes it difficult to follow steps of a
task and listen to directions.

P: The client will be treated for 60-minute minute sessions 3/week for 4 weeks to address
motor control, L side neglect, L body neglect, impulsivity, and attention deficits that interfere
with occupational performance in ADLs and iADLs including tasks related to her job, managing
medication, showering, dressing, caring for her dog, and others. Skilled OT services are required
for appropriate grading of activities that will address these performance deficits. The client’s
complex condition requires advanced clinical judgment to adjust the presentation of activities
that will properly challenge them while teaching them to generalize strategies, such as
addressing attention by removing distractions from the environment, beyond the treatment
session.

Goals:

LTG1: By discharge, the client will IND complete LB and UB dressing using adaptive strategies.
STG 1a: In 3 weeks, the client will actively incorporate her LUE while donning a button up shirt
with no more than 1 verbal cue.
STG 1b: In 2 weeks, the client will IND take proper safety precautions when LB dressing using
adaptive strategies.
LTG 2: By discharge, the client will IND manage her medications in a 1-week pill organizer.
STG 2a: In 3 weeks, the client will IND place a child-proof pill bottle in her L hand and open it
with her R hand.
STG 2b: In 2 weeks, the client will attend to managing medications with no more than 1 verbal
cue.
Signature: Isabel Austin OT
Date: 3/30/21