Occupational Therapy Evaluation Report and Initial Intervention Plan

Background Information

Client’s name or initials: VB

Date of referral: 1/10/2019

Date of Report: 1/24/2018

Date of birth &/or age: 22 years old

Primary intervention diagnosis/concern: R CVA

Secondary concerns/diagnosis: none reported

Precautions/contraindications: reported L field cut and inattention

Medications: none reported

Reason for referral to OT: R CVA

Therapist: Linda Ng, OTS, and Mackenzie Carter, OTS

_____________________________________________________________________________________

Subjective:

Client expressed her desire to return to school in the summer semester, and hopes to still graduate in

Spring 2020.

Objective:

Client was seen 1/17/2019 and 1/24/2019 for a comprehensive occupational therapy evaluation.

Occupational profile: VB is a 22-year old woman who had a R CVA on 9/11/2018. She is a junior at the

University of Utah, studying Material Sciences, and hopes to graduate in the spring of next year. VB is

currently auditing a class to help her prepare for returning to her major for the summer semester. She is

currently seeing outpatient OT, PT, and ST at Sugarhouse Rehab, and is seeking further OT services to
work on occupations impacted her LUE hemiplegia. She lives in the basement with her brother at their

two story family home in West Valley, which includes her mother, father, younger sister, older brother,

and two pets; her older brother and his family do not live with them. VB reports that she is independent

with all her ADLs with the use of some adaptive equipment. She previously worked at Burlington Coat

Factory as a cashier and stocker, but does not intend to return. She currently relies on her parents for

transportation, but would like to return to driving. VB enjoys cooking, going out and shopping with

friends, spending time with her nephew, reading, swimming, and hiking. Her parents reported that she

sometimes forgets to turn off the stove top during cooking tasks, and has burned herself before. VB is

bright, friendly, has a variety of hobbies, and has the support of the friends and family in her life.

Assessments Administered:

- COPM: a semi-structured interview used to identify areas of occupational concern and areas for

intervention. Assessment includes client’s perceived level of importance, performance, and

satisfaction. The following are her priorities and scores:

Occupational Concerns/Priorities for Intervention Importance Performance Satisfaction

1. Driving 10 1 1

2. Cooking 10 5 5

3. Typing 10 1 1

4. Swimming 10 1 1

5. Strategies for school 9 5 4

Total: 49 13 12
Average: 9.8 2.6 2.4

Due to the limited time available at student clinic, VB was asked to narrow down to three goal

areas to focus on. Since her driving goal was not practical for the setting, it was removed as a priority.

She then agreed on cooking, school strategies (including typing), and swimming as priorities.
 - Modified PASS: a performance-based observational tool to better document and identify the

client’s needs in functional activities, using the hierarchy of cues. Only the “Oven Use” and

“Obtaining Critical Information from the Media” (visual) sections were administered.

Observations during this assessment are included in the next section.

Independence Safety Adequacy

Oven Use (Meal Preparation) 2.66 3 3

Obtaining Critical Information 3 3 3

from the Media (Visual)

Observations:

On 1/17/2019, VB performed a packing task that included: zipping/unzipping, organizing papers,

and moving objects in and out of the backpack. Client used her dominant R hand to complete tasks, and

was prompted to use her L hand for the activity; which she did with mod physical assist to hold the

backpack open. Client also needed min VC and min A to incorporate L hand when putting papers into a

folder. Client also performed a cooking task that required her to search and move through the kitchen to

find necessary materials for the predetermined task, and then complete the cooking steps. Client was

faced perpendicular to the cooking surface she was working on, with her left side away from the

counter. VB was asked to read instructions from the carton and name the steps that she was working

on, which she did without indication of skipping steps; which was mentioned as a problem area in the

interview. VB washed dishes, and used her L arm to turn off the faucet with some difficulty.

On 1/23/2019, VB was given a scheduling activity of which auditory instructions were given for

her to organize. She demonstrated realistic reasoning skills; however, she also indicated that she has

done the activity before. VB used her RUE to open and take out a notebook from her backpack. She

explained her strategies for using her planner, and also demonstrated understanding of her own notes

from class by explaining the content. VB then packed her notes back into the backpack with her RUE,
and used her LUE towards the end to hold open her backpack, without VC. For the next activity, VB

primarily used her RUE for dishwashing. She had two VCs to remember incorporate her LUE in the

activity, and needed mod physical assist to maintain LUE placement. During the PASS, VB safely turned

off the oven in an appropriate amount of time, and used oven mitts for safety. She required mod assist

to open the muffin package, and also dropped a muffin during transfer from tin to plate. VB also was

distracted by others in the room on one occasion, during the visual obtaining information portion of the

PASS.

Assessment:

From observation and assessments, VB demonstrated decreased L UE motor function,

decreased cognition and attention. VB demonstrated decreased LUE motor function, as observed by

non-use of her LUE in typically bilateral tasks. These motor deficits impede her ability to independently

cook, participate fully in school, drive, and swim, among other important occupations. The client also

shows decreased attention. The client expressed realistic reasoning skills during the scheduling activity.

We intend to further assess her ability and effectiveness to utilize those strategies that may be

implemented for return to school.

VB shows good rehab potential. Her parents and friends are very supportive of her and her

rehabilitation efforts. She is also receiving several therapy services to help her. She demonstrates desire

to work hard and improve, in order to regain some independence.

Plan:

Practice Models to be used to guide treatment:

PEO: In this model, the therapist facilitates occupation by changing the aspects of the person

(P), environment (E), and occupation (O), in order to promote participation in desired occupations (Law,

et al., 1996). For VB to engage in school, swimming, and cooking, these areas can be addressed or
changed so that she can participate safely and in the way that she needs to. We intend to focus on

aspects of the person through addressing motor control in her LUE. We may also change the

environment and occupation (e.g. external cues, structure for reminders, or simplifying the task) to

support participation in occupation as they come apparent, also to support her participation in desired

occupations.

Motor Control Model: This model postulates that the nervous system has plasticity and

potential for reorganization of movement patterns, as the result of experience. By promoting the

inclusion of her affected LUE in activity, those changes in the nervous system can improve the client’s

participation and quality of participation in her desired occupations. Practice in varying and natural

contexts will also promote changes in her nervous system. Postulates of this model infer that

modifications to personal and environmental characteristics can improve VB’s performance in activity.

We intend to address VB’s motor control in her LUE by promoting inclusion of it in varying and natural

contexts, and changing characteristics, in order for her to participate more fully in her desired

occupations. A study by Massie, White, and Funke (2016) studied the use of motor control rehabilitation

principles to elicit change in motor control and dexterity. Though a short study, it demonstrates the

importance of use and exercise to influence neuroplasticity.

Rehabilitation Model: This model aims to build role competence and fulfillment of daily

activities. This primarily looks at compensation, adaptation, and environmental changes as intervention.

By providing VB with compensatory strategies, occupational and environmental modifications, she may

be better equipped to improve her occupational performance, and thus better participate in school,

ADLs, and cooking.

Skilled occupational therapy services at the University of Utah Occupational Therapy student

program is recommended for 60-minute sessions 1x/week to address decreased UE function, decreased
cognition, and inattention, which are affecting VB’s ability to participate effectively in many of her IADLs.

The client indicated her priorities for occupational therapy in the COPM, and the intervention goal areas

to be addressed are as follows:

● LTG1: In 5 visits, with min assist, client will prepare a simple meal while using LUE to stabilize

materials.

o STG1: In 3 visits, client will cut vegetables with min assist by stabilizing ingredients with

her LUE and the use of adaptive equipment.

o STG2: In 4 visits, client will mix ingredients with mod assist to stabilize LUE on materials.

Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
Much Less Less Expected Level Better Much Better
(Occupation/Target  Prepares simple  Prepares  Prepares  Prepares simple  Prepares
Behavior): Prepare meal simple meal simple meal meal moderate meal
a simple meal  Uses LUE to  Uses LUE to  Uses LUE to  Uses LUE to  Uses LUE to
stabilize stabilize stabilize stabilize stabilize
materials 25% of materials 50% materials 75% materials materials
the time of the time of the time  Done  Done
 Max assist  Mod assist  Min assist independently independently
Proximal Outcomes (STGs) Measurement Criteria Baseline
1) Cut vegetables using Level of assist Max assist for LUE
LUE Amount of LUE use Mod-max assist for whole task

2) Mix ingredients with Level of assist Max assist for LUE use
LUE Amount of LUE use Mod-max assist for whole task
Level of activity completeness (mixed
ingredients)

● LTG2: In 5 visits, client will use adaptive strategies for a portion of a basic lab report, in order to

return to school.

o STG1: In 3 visits, client will navigate computer while using a computer adaptive strategy.

o STG2: In 4 visits, client will type one sentences with min assist and a computer adaptive

strategy.
Distal Outcome -2 -1 0 +1 +2
(LTG): (Baseline) (Goal)
Much Less Less Expected Level Better Much Better
(Occupation/Target  Complete portion  Complete lab  Completes  Complete lab  Complete
Behavior): Use of lab report report portion of lab report complex/
adaptive strategy  Use adaptive  Use adaptive report  Use adaptive comprehensive
strategy 50% of strategy 70% of  Uses LUE to strategy lab report
time time stabilize materials  Done  Use adaptive
 Mod assist  Min assist 75% of the time independently strategy
 Min assist  Done
independently
Proximal Outcomes (STGs) Measurement Criteria Baseline
1) Navigates Computer Level of assist Mod-max assist
Use of computer adaptive strategy Minimal computer use
No computer adaptive strategy

2) Type two sentences Level of assist No typing

Amount typed Max assist
Use of computer adaptive strategy No computer adaptive strategy

LT2: Within 4 visits, client will begin a task with min VC for self-cuing, after full verbal

instructions are given.

ST2: In 2 visits, client will follow verbal instructions with mod VC for a 3-step activity.

ST2: In 2 visits, client will begin task with mod VC for self-cuing to ensure full verbal

instructions are given.

By providing opportunities and skilled services in the lens of practice models, VB may be able to

improve her participation in her school, leisure, and other IADL occupations.

Therapist Signature ___Linda Ng________ Date __1/24/2019_

 References

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-environment-

occupation model: A transactive approach to occupational performance. Canadian Journal of

Occupational Therapy, 63 (1), 219-234.

Massie, C., White, C., & Funke, D. (2016). Impact of motor practice on neuromodulation for stroke

rehabilitation. American Journal of Occupational Therapy, 70. doi:10.5014/ajot.2016.70S1-

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