Name: Meg Nielson

SOAP Note

Demographic information:

Name: Janis Melbourne

Date of report: April 9, 2019

Diagnosis: 4 weeks post Right hemisphere traumatic brain injury

S: Client was agreeable to evaluation. She stated “so I’m putting the medication down just like in
the Bingo game we played last time.”

O: Client was seen on April 6, 2019 and April 9, 2019 for a comprehensive evaluation including
occupational profile interview, COPM, PASS, Fugl-Meyer, and observation of occupational
performance.

Occupational Profile: The client is a 45-year-old female who lives at home with her husband and
15-year-old son. She is seeking occupational therapy services status post car accident. Prior to
her accident, she was working full time as a Human Resource representative for a large
technology company. Currently, she is on medical leave and would like to return to work soon.
Her husband also works full time but is able to stay at home with her for 3 more weeks after
which the client will be home alone or with her son. Her son is staying with family while she is in
therapy. The client’s husband is currently doing the house work and supportive of the client in
her therapy needs. The client was doing the house work prior to her accident. The client has a
dog that she loves to take care of and play with. She is active in the community attending a
weekly spiritual group and volunteering with her dog. She enjoys hiking with her dog, mountain
biking, and camping. The client is currently having difficulty in her everyday tasks such as
dressing in work clothes, medication management, showering, walking and playing with dog,
and is unable to return to work at this time and would like to return to doing these activities
independently.

Observation: The client was seen in her home. The client’s dog was present and she was easily
distracted by the dog. She continually wanted to play with the dog rather than make her snack.
The client was asked to make a snack of crackers and cheese. Client used her right leg to
maneuver her wheelchair around the house. She needed several verbal prompts to keep her
attention to the task of retrieving crackers. She was easily distracted by drawers and would
frequently open them and look at items in them. She retrieved the crackers and placed them on
the counter. The client asked about turning the Christmas lights on three times with a verbal
directive prompt each time. The client opened the fridge and pulled out three items before
finding the cheese. She then left the fridge without closing the left door and required a verbal
non-directive prompt to close it. The client used her right hand to lift left hand into sink to wash
hand. The client pulled out five knifes when asked to slice the cheese. She was able to slice the
cheese using her right hand. When retrieving crackers out of box, she used her left arm to
stabilize the box to pull crackers out. The client places three pieces of cheese on cracker for
therapist and after prompt for only one she still put two on the cracker. Client’s dog returned and
she got distracted. While she was leaning forward to pet dog, wheels of wheelchair came off the
ground.

COPM: A semi-structured interview to identify problem areas for the client and to guide goal
setting.

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
20 17
TOTAL
4 3.4

PASS: A client-centered assessment that evaluates client’s ADL and IADL performance.

Independence Safety Adequacy

Dressing 2.5 2 1
Money Management: 1.8 3 1
Shopping
Medication 2.1 2 1
Management
Playing Bingo 1.5 3 1

Money Management: Shopping- The client required verbal non-directive and verbal directive
throughout to keep attention on the task. The client was slow to find the four items and was not
able to correctly gather them without cuing. She was easily distracted by the names of the
soups and looking for recipes on the cans. She did notice that one of the sauces had expired
and mentioned she would not cook with it. The client did not want to give the correct amount of
cash because she knew in a real store she would get change back. She required cuing and
redirection to get the correct amount of money. The client was able to select the correct coupon
after the first try with non-directive cuing. After non-directive cues, she was able to identify that
the change was incorrect and calculate how much she needed.

Medication Management: The client also required verbal non-directive and verbal directive
throughout this task for attention. She was able to complete tasks 4 and 5 independently. She
required verbal non-directive to report medication time. With the child proof bottle, the client
required assistance to open the bottle. The therapist held the bottle on the table and the client
pushed and turned the lid. When the client poured the medication out, she immediately put one
in her mouth. She did not know the date and placed the medication on the wrong dates and
required verbal prompts to correct herself. With the second bottle, the client places the pills on
all the times after reading the prescription instructions and required verbal prompts to correct
self.

Fugl-Meyer Chart: Evaluation of the upper extremity and the movement patterns.

A. Upper Extremity 16/36

B. Wrist 2/10
C. Hand 5/14
D. Coordination/ Speed 3/6
Total A-D (motor function) 26/66

H. Sensation 12/12
I. Passive Joint Motion 24/24
J. Joint Pain 24/24

A: The client demonstrated lack of attention to task as evident through the observation of
occupational performance and the PASS. The lack of attention to task is likely due to right
hemisphere TBI and is impacting client’s ability to complete simple ADL and IADL tasks such as
dressing, meal preparation, medication management, showering, functional mobility, and would
hinder her work performance. The client also frequently forgets what she is doing throughout
PASS and home observation. The client is also having difficulty with the use of her left arm in
functional tasks which is causing difficulty with ADL and IADL tasks such as dressing and meal
preparation. On the PASS tasks, the client’s adequacy score was a one meaning that she
completed the tasks with missing steps and with a lack of precision. This was also evident in
home observation. The client was repetitive in her actions and required redirect often. This will
likely affect her performance at work. Client’s lack of safety awareness was made evident
through home observation in her wheelchair. She did not notice that she was too close to the
stairs, that she was sitting too far forward, or that it was dangerous to lean forward and have
wheels come off the ground.

The client is positive and motivated for therapy. She would like to return to work as soon as
possible. She has family support and her home is rather accessible. The client was active prior
to her accident and would like to return to being as active as possible. The client would be a
good candidate for skilled occupational therapy services to address attention, memory, safety
awareness, insight, work related skills, and ADLs and IADLs.

P: Client will be seen 3x/week for 4 weeks. Intervention will include ADL and IADL training,
education on compensatory strategies and adaptive equipment, and work related skills to
address attention, memory, safety awareness, work performance and ADLs/IADL performance.
Goals:

LTG1: By d/c, client will shower with modified independence.

STG1a: Within 10 visits, client will open containers utilizing L arm as support with min A.

STG1b: Within 5 visits, client will transfer from w/c to shower bench with supervision for safety.

LTG2: By d/c, client will dress self in work clothing independently.

STG2a: Within 10 visits, client will button 8/10 buttons on shirt with min A.

STG2b: Within 5 visits, client will don and doff LB work clothing with min A.
 INTERVENTION PLAN FOR COMMUNITY CLIENT

Copy/paste one LTG and the matching STG from your evaluation SOAP note. This will be the goal set around which you design your treatment session.

Long-Term Goal 1: By d/c, client will shower with modified independence.

Short-Term Goal 1a: Within 10 visits, client will open containers utilizing L arm as support with min A.

Long-Term Goal 2: LTG2: By d/c, client will dress self in work clothing independently.

Short-Term Goal 2a: STG2a: Within 10 visits, client will button 8/10 buttons with min A.

OCCUPATIONAL OPM and CPM TREATMENT SESSION GRADING THE ACTIVITY

PERFORMANCE PROBLEM
Specifically identify only the client
factors and/or performance skills
that are barriers to the
achievement of this goal. This
should not be a bullet list, rather
you should describe how the client
factor impacts this client’s
performance of the occupation in
the goal.
Grips: Janis in not currently using
her left hand in most daily tasks.
She is not gripping onto items at
all. According to the Fulg-Meyer,
she has partial cylinder grasp so
incorporating and using that grasp
to hold onto shampoo and
conditioner bottles can increase
her independence.
Coordinates: Once again, Janis is
not incorporating her left arm into
much of her daily routine. She is
not using it to stabilize items.
Attention: Janis is easily
distractible and frequently looks
AND RATIONALE
Identify your OPM and all relevant
CPM’s that best addresses the
performance problem and describe
how each will be used to design
treatment for this client’s specific
problems.
PEO: With Janis, we need to
consider her environment and her
occupations and how they are
interacting with each other. We
want to find congruence between
the three. She is currently having
difficulty with showering
independently and therefore, the
occupation and environment should
be considered as they may need to
be adapted so that she can have a
more optimal occupational
performance.
Rehabilitation Model: Janis will
need to be taught compensatory
strategies especially in regards to
DESCRIPTION Choose one client factor or
Provide details of how you will set up performance skill that you address
the activity and how your intervention in your treatment session. Describe
addresses the performance problem. one way (only one) that you can
Your description should detail how grade the activity up and one way
the activity will be set up to make it (only one) to grade the activity
therapeutic. down based on that one factor or
skill.
Factor/Skill:
Janis will be seated on her shower Grading down: Holding and opening
bench in the shower. This will just be one container
practicing how to hold the containers
of shampoo and conditioner so she Grading up: Holding and opening
will be fully clothed. She will be multiple containers
required to reach and grab the
containers and then try to open
them. I would like to see Janis’s
ability to problem solve first and see
if she is able to come up with a new
way to open the bottle. If she is
unable to find a way, I will provide
some strategies for her such as
holding the bottle with her left hand
or holding it under her left forearm.
We will practice these techniques
and see if anything works for her. If
away from the task or starts talking
about different things.
Manipulates: Janis is not using her
left hand and therefore, buttoning
smaller buttons on a blouse could
be difficult for her. It is more
difficult to only use one hand.
Coordinates: Once again, Janis is
not incorporating her left arm into
much of her daily routine. She is
not using it to stabilize items. It
could be useful to stabilize her
shirt or the buttons on the shirt.
the use of her left arm. She is not
currently using it much but could
incorporate it more into her
everyday tasks. Adaptive
equipment may also be required.
PEO: With Janis, we need to
consider her environment and her
occupations and how they are
interacting with each other. We
want to find congruence between
the three. One of her goals is to
dress herself in her work clothing.
Due to the fact that her left arm
does not have as much active
movement and she is not using it
much, it may be difficult to dress
herself in a button up blouse.
Therefore, the environment and the
occupation need to be taken into
consideration to adapt or change
the way they are being done to
improve Janis’s independence and
meet her goals.
Rehabilitation Model: Janis will
need to be taught compensatory
strategies especially in regards to
the use of her left arm. With
dressing, she may need to learn a
new way of dressing that is
strategic with her left arm. She is
not currently using it much but could
incorporate it more into her
everyday tasks. Adaptive
equipment may also be required for
buttons.
she is still having difficulty, having
her stabilize the bottles between her
knees and pulling the lid off with her
right hand. Although, I would like to
encourage her to use her left hand
and arm as much as possible.
Client needs continuous redirect as
she is easily distracted. So keeping
that in mind throughout session to try
and keep her engaged in task.
Janis will be seated at the EOB. She Grading down: A shirt with less
will be required to pick out a button buttons
up shirt that she enjoys wearing to
work. Once the shirt has been picked Grading up: A shirt with more
out, Janis will be required to put on buttons that are small.
the shirt. If she is not putting her left
arm in the shirt first, a new strategy
to make it easier will be introduced.
She will thread her left arm into the
shirt first making it easier to pull
around her shoulders and thread her
right arm in. Once that is complete, I
would like Janis to stabilize the
buttons and shirt with her left arm. If
the buttons are too small and she is
unable to, I will then teach her to use
a button hook for those smaller
buttons. The use of a button hook
may be useful for Janis although I
would like to encourage her to use
the left arm and hand as much as
possible to retrain it through ADL
tasks.
Client needs continuous redirect as
she is easily distracted. So keeping
that in mind throughout session to try
and keep her engaged in task.