Diagnosis Description and ICD-10 Code:

Diagnosis: Mild cognitive impairment of uncertain or unknown etiology

ICD-10 code: G31.84
CPT Code:

Precautions/medical history:
PMH:
Precautions/contraindications:

The client was diagnosed with a mild cognitive impairment a year ago. She has active primary
hypertension, unilateral primary insomnia, and mixed hyperlipidemia. She has a resolved post-
traumatic osteoarthritis of the right hip.

Medications:

 Acetaminophen 325 mg up to 650mg PRN Daily

 Ambien 5mg Oral At bedtime
 Anselol 50mg tablet Daily
 Rosuvastatin calcium 10mg Oral BID

Subjective

Occupational Profile:

Client Chris Smythe is a 73 y/o woman who is widowed and lives alone. The client was referred
to occupational therapy for mild cognitive impairment. The client has been experiencing a
memory decline and tends to forget people, places, and events. She is independent in routine
self-care activities. The client does not drive but uses Meals on Wheels to get meals during the
week. She has people from the church community come by sometimes, but it is not frequent.
Client has trouble taking medications on time and taking the correct pills.

Social history:
The client lives alone in a two-story house with three beds, and two and a half bathrooms. She
does not have close support other than people from her church community who come by
infrequently. States that she wants to interact more with her neighbors. She used to be active in
her church community but cannot drive so she does not go as much anymore. The client’s
favorite occupations include cooking and going to church.
Subjective:
The client states that “driving is scary”. The biggest concerns are that she forgets to turn off the
stove after she is done cooking and is worried about taking her medications correctly. She said
she goes out to walk if it is sunny but gets “tired after a little”. She also does not want any
assistive technology that is “too techy”.

Patient concerns/priorities:
The client wishes to be taking her medication on time and the right dose. She wants to have
safety awareness for cooking around the stove. She wants to be more social with her
neighbors.

Objective

Vital signs:
Blood pressure: 134/92
Pulse: 66
Pulse Oximetry: 95%
Respiration Rate: 14 breaths per minute
Client presents as AOx4.

Pain assessment:
Pain: 1 on a scale of 1 to 10
Since client reported no pain, we did not ask intensity, descriptor, or location

Physical environment
Exterior entrances & exits:
Walkways: The walkway space is dependent on how the client is parked in the driveway but
shows limited space.
Lighting: There is overhead lighting is present over the entryway.
Threshold: No steps present.
Door width:
Back door: Sliding glass door with no step-down.
Garage: Connected to the apartment. Standard one-car garage located left of the front
doorway. The interior door enters outward into the hallway entry.

Interior doors, stairs, hallways:

Lighting and controls: The first set of controls is at the bottom of the stairs and the remaining
are in the interior hallway heading to the kitchen on the right.
Floor space and surface: Around the entryway is clustered with shoes and backpacks.
Stairs: Carpeted with railing on the right.
Hallways:

Bathroom(s):
The downstairs bathroom: ½ bath that is located under the stairs
Upstairs bathroom: Full bathroom, tub/shower combination with liner.
Master bathroom: Full bathroom, shower with liner.

Kitchen:
Location and condition of stove controls: Controls on the back of the stove with black writing
on top of white surfacing, small lettering, and good conditions
Garbage disposal: n/a
Sink/basin and controls: Located on the “island” across from the stove. Double-bowl, stainless
steel drop-in kitchen sink
Lighting and controls: Interior hallway heading to the kitchen on the right.

Living, dining, bedroom:

Rug with non-slip pads: Placed in between the couch and the tv.
Access to closet: Bedroom Includes bifold doors and included in the master is an open plan
closet before the master bathroom.

Laundry:
The laundry machines are upstairs along the hallway between the bedrooms and across from
the upstairs bathroom. Two sliding doors that fold outward cover the washer and dryer. They
are two separate machines with the washer doors opening upward and the dryer door opening
outward.

Basement: n/a

Safety:
Smoke detectors: Present in the kitchen and all bedrooms.
Fire extinguishers: Left of the door in the garage.
Thermostat controls: Located upstairs outside of the door to the master bedroom.

Computer workstation:
When seated at the computer workstation the client’s knees, elbows, and head were at 90
degrees.

Occupational Performance:
ADL performance:
The client was able to wash their hands independently.

IADL performance:
The client was able to use a toaster on her own. Needed verbal cueing to not put butter on the
bread before cooking in the toaster. She also dialed a phone and asked the person on the other
line a question.

Health management:
The client was able to correctly sort medication after some direction.

Rest and sleep:

n/a

Transfers:
n/a

Functional mobility:
The client was able to move around freely while performing the test. She was able to transport
objects without any trouble.

Performance Skills/Actions/Movements:
The client stabilized by moving through the room without losing balance. The client positioned
their body at an effective distance from all parts in the test, she sat when needed and stood
when needed. The client reached, bent, gripped, and manipulated the medications, belts, wash
items, phone, and toast items. She coordinated her body parts to complete different subtasks
such as picking up medication out of the bottle or lifting belts to inspect them. She moved,
walked, and transported items and self without any trouble. She endured, paced, heeded, and
attended to the different parts of the test, she did not fatigue. She applied knowledge by
inquiring when she had a question. She sequenced her steps in a logical order but needed
cueing to complete the tasks correctly.

Client Factors:
The client has a mild cognitive impairment which interferes with her way of living. Her higher-
level cognitive function was shown to be limited when she was not able to correctly sort the
medication or choose a belt that fit her properly. Her insight was decreased when she tried to
put butter on the bread before toasting it. Her attention and memory affect her safety
awareness when cooking as she forgets to turn off the stove. Her visual, hearing, vestibular,
taste, smell, proprioceptive, and touch functions are intact. She had little pain as indicated by
her score of 1 when asked. Her voice and speech functions were intact. She was oriented to
person, place, time, and why. Her energy level was good. Sometimes she does not fall asleep
right away when going to bed.

Assessment

Summary: The client shows mild cognitive decline. She is independent in routine self-care
activities. The client has trouble completing some tasks without cueing. Her memory and
attention are affected by the decline.
Functional Problem Statement: The client shows difficulty with planning and sequencing
tasks that have resulted in a safety concern.
Rehab Potential: The client shows willingness and excitement for treatment but may be
impacted by a limited support system.
Potential Benefits to Receiving Interventions: The client will be able to manage their
medications on their own and safely cook in their home.
Potential Risks Associated with not Receiving Interventions: The client may take the wrong
medication or at the wrong time which would affect her body in a negative way. If we do not
address safety awareness around cooking there may be a fire caused by leaving the stove on.

Plan

Overview of Intervention Plan:

Frequency: Once a week for 8 weeks
Duration: One-hour sessions
Location: In home/ telehealth
Foci of Services: The focus is on managing cognitive decline by medication management and
increasing safety awareness around cooking.

Targeted Outcomes:
Outcome 1: Quality of life- The client states that she’s afraid of hurting herself due to cognitive
decline.
Outcome 2: Occupational Performance Improvement – The client shows difficulty with planning
medication management and will use assistive technology to improve her occupational
performance.

Goals:
LTG 1: The client will independently manage medication using on time and dosage 100% of the
time by the end of May.
STG 1: The client will use an adaptive pillbox under modified independence to sort her
medication 80% of the time by the beginning of May.
STG 2: The client will use an adaptive pillbox under supervision to sort her medication 70% of
the time by the middle of April.
Approach to Intervention: Modify the client’s task in preparing and timing of medication
management.
Type of Intervention: Education and Training of Assistive Technology will be addressed by
introducing medicine organizer to assist in medicine management.

LTG 2: The client will use a cooking checklist independently 90% of the time by the end of May.
STG 1: The client will use a cooking checklist with modified independence 80% of the time by
the beginning of May.
STG 2: The client will use a cooking checklist under supervision 70% of the time by the end of
April.
Approach to Intervention: Modify will be addressed by creating a checklist for cooking.
Type of Intervention: checklist: Activities will be addressed by self-monitoring sequencing of
cooking tasks.