S: The client reported improvement in work and home performance due to participation in

occupational therapy.

O - The client was seen for OT 1x/wk for 8 weeks. The client presented with difficulty

independently organizing, remembering, and planning work tasks at his full-time job. He also

presented with difficulty independently grocery shopping. Goals were created in

collaboration with client targeting job participation and grocery shopping. During treatment,

the client received client education, informational handouts, and training on the use of

technological aids and implementation of compensatory cognitive strategies. He engaged in

client-centered, purposeful, and functional activities targeting occupational performance. Due

to therapeutic intervention and the use of compensatory cognitive strategies, the client

improved in all areas targeted by therapy. Positive outcomes were noted in therapy and by

client self-report. By d/c, the client independently implemented daily workflow and shopped

for groceries using cognitive strategies.

A - The client was a willing participant in therapy and incorporated strategies learned in

therapy, both in treatment sessions and in the course of daily occupations. The client

achieved all therapy goals. The client initially required modVC in order to utilize cognitive

strategies to complete functional tasks. By d/c the client independently incorporated

strategies while completing functional tasks. Improvements were seen due to the client’s

increased understanding of strategies and awareness of when to apply them. The client

implemented both internal and external cognitives strategies and improved his ability to

apply such strategies through daily practice. He successfully implemented the use of

technological aids to assist organization, planning, and memory. The client gained greater

insight into his performance by using metacognitive strategies to assess performance before

and after tasks. Outcomes of the occupational therapy process included occupational

improvement, role competence, and well-being.

P - The client was provided resources for reference on topics including attention, memory,

planning, organization and categorization, and rehearsal of information. The client received a

home program for further practice of strategies in daily life in order to facilitate continued

improvement in areas of occupational performance, role competence, and well-being.

LTG #1: By d/c, the client will independently implement daily workflow using
compensatory cognitive strategies for planning and organization. (Goal complete)

STG #1: By d/c, client will resolve his daily emails using an established compensatory strategy,
per self-report. (Goal complete)

STG #2: By d/c, client will complete a multi-tab computer activity in 30 minutes with min VC to
use compensatory cognitive strategies for organization. (Goal complete)

LTG #2: By d/c, the client will independently shop for groceries using compensatory
cognitive strategies for planning, organization, and working memory. (Goal complete)

STG #1: In three weeks, client will obtain all items on a shopping list without misplacing his cart
or list with min VC for working memory. (Goal complete)

STG#2: In three weeks, client will plan a grocery shopping trip with min VC using compensatory
cognitive strategies for planning and organization. (Goal complete)

Outcome -2 -1 0 +1 +2
 Target -Shop for -Shop for -Shop for -Shop for -Shop for
Behavior groceries groceries groceries groceries groceries
with mod VC with min independently independently independe
VC without ntly
- Often - Not backtracking without a
forgetting - forgetting cart for items. list.
some items or Occasionall or items.
cart y forgetting -Use of -Use of
cart or -Use of compensatory compensat
items compensatory strategies ory
strategies strategies

Outcome -2 -1 0 +1 +2

Target -Unorganized -Organize -Organize -Organize and -Organize

Behavior email email with email manage email and
assistance independently by the end of manage
-Emails the day email at
slipping -Leave a -Use of the end of
through the few things compensatory -Use of every
cracks unhandled strategies compensatory single day
strategies
-No emails
slipping
through the
cracks