Vanessa Russell

SOAP Note- Initial Evaluation

Background: Client is a 45-year-old female referred from inpatient rehabilitation who sustained a
R TBI 4 weeks ago as a passenger in MVA.

S: When told to reposition herself in her w/c, client stated “Oh I won’t fall!”

O: Client was seen 03/31/20 and 04/07/20 for an initial occupational therapy evaluation, which
included an occupational profile interview, completion of the Canadian Occupational
Performance Measure (COPM) and sections of the Performance Assessment of Self-care Skills
(PASS), observation of occupational performance, and the Fugl-Meyer Assessment of Upper
Extremity (FMA-UE). The outcomes of these assessments are given below.

Occupational Profile: Client is seeking skilled occupational therapy services for improvement in
multiple occupations. She is supported by her family, social groups, and previous active
lifestyle. Her husband of 2 years frequently reminds her to take her medication and has 3 weeks
of medical leave from his job to assist with her recovery. Once he returns to work fulltime as
firefighter, 24 hours on and 48 hours off, she will be home alone or with her 15-year-old son,
who she often helps with homework. Together, client and her husband have a combined family
of 4 children from previous relationships. Client’s son and the 3 children of her husband do not
live at home. Currently, her son is staying with his father while Client is in rehabilitation.

In therapy, there are many occupations client would like to improve upon. She can groom and
dress herself in pullovers, however she would like to shower without assistance and dress in her
work clothes. She uses a w/c and can walk a few steps with assistance but would like to be able
to perform many of her previous leisure and recreational activities, including mountain biking,
camping, hiking and walking with her dog. Additionally, prior to her accident, Client worked full
time as a Human Resource representative for a technology company, volunteered with her
therapy dog, and attended a spirituality group once a week; these are all occupations she would
like to return to and have prioritized in the COPM.

COPM: The COPM is a semi-structured interview that assists in establishing client priorities for
intervention by assessing their perception of performance and satisfaction with that
performance. The assessment uses a 1-10 rating scale, a rating of 1 in the performance section
corresponds to not being able to perform the task and a rating of 10 corresponds to performing
extremely well. In the satisfaction section, 1 corresponds to not at all satisfied and a 10
corresponds to extremely satisfied.

Occupational Performance Problems Performance Satisfaction

Returning to work within a few months 3 2

Taking medications independently 8 8

Showering and dressing 7 5

Time with dog (walks, volunteer work) 1 1

In/out hot tub 1 1

 Vanessa Russell

TOTAL/AVERAGE 20/4 17/3.4

PASS: The PASS is a performance-based tool to assess independence, safety, and adequacy
of occupational performance in various ADL and IADL tasks.

Task Independence Safety Adequacy

Dressing 2.5 2 1

Grocery Shopping 2.2 3 1

Medication Management 1.6 3 1

Playing Bingo 1.5 NA 1

Dressing task: Gestural cuing to get L arm in sleeve. D VP to stabilize the garment with her L
hand. Donned hosiery independently, but it took a long time. Required a demonstration of how
to tie shoes using L hand to stabilize as R did the work.
Grocery shopping: Required 1 D VP to select appropriate items and give correct change.
Required 2 non-direct VP to give correct change and recognize change returned was incorrect.
Medication management: Required 2 D VP to correctly identify next dose and total assistance to
open child proof lid. When distributing pills on pill chart, she initially required gestures to
correctly identify when next dose was due, the second time she required 1 D VP. When seeing
the M&M’s used as pills, she immediately ate one.
Playing Bingo: Needed cues to listen to the caller and missed numbers being called out due tp
talking. Required cuing to redirect to task. Did not call Bingo and did not notice she had Bingo
with D VP.

Observation of occupational performance: Client was observed in her home while seated in a
manual w/c. She was instructed to prepare a snack of cheese and crackers. She used the R
side of her body to propel the w/c, hitting objects on the L side, and kept her L UE in her lap and
L LE rested on the footrest. To complete the task, she required 5 + direct and non-direct VP to
redirect her from things in the environment. She required 1 direct VP to stay away from the edge
of the top of the stairs. When she went to turn the lights on, she flipped the same switches
multiple times and stopped when larger lights did not turn on; she later required D VP to turn on
correct lights. She required 2 D VP to open and close the L side of the fridge. To cut the cheese,
she placed several large knives on the counter and required 1 non-direct VP to choose the
smaller knife. She required 1 non-direct VP to stop cutting the cheese and returned to the task 2
more times, using a different knife and requiring D VP to stop each time. She used her mouth to
open packaging. She required 1 D VP to reposition herself in her w/c as she had moved to the
edge while reaching for objects on the counter. To move cheese and meat on to her plate, she
placed them on the edge of her knife. While opening the box of crackers, she used her L arm to
stabilize the box as her R UE opened it, otherwise her L UE remained at her side. She required
2 D VP to place only one piece of cheese on the crackers. When bending forward in her w/c, the
back wheels lifted off the ground, she sat up and laughed.
 Vanessa Russell

FMA-UE: Assessment of sensorimotor function of the upper extremity.

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: Client is bright and motivated to progress in her recovery. She is challenged by time limits
placed on her husband and caregiver to return to work. In addition, many of her daily
occupations have been disrupted by deficits in motor control, as demonstrated by poor L UE
volitional movement; and cognition, as demonstrated in being easily distracted by her
environment, lack of insight to her performance, and inefficiency when completing tasks. Her
lack of insight, impulsivity, and poor attention pose concerns for her safety when maneuvering
her w/c and completing IADL’s. While her sensorimotor function is impaired in her L UE, as
assessed by the FMA-UE, she has wrist extension, thumb abduction, and intact sensation,
which are positive indications for recovery. She also has preservation of function in her
dominant R UE, which will enable her to use compensatory strategies while improving motor
control of L UE. With a history of a healthy and active lifestyle, a good support system, and a
positive and friendly disposition, Client shows potential to improve her performance in daily
occupations through skilled occupational therapy services.

P: Skilled occupational therapy services will be provided for 4 weeks, 3 sessions per week, 1
hour per session. Skilled therapy services will include training on the use of compensatory
strategies and adaptive equipment, motor control, and energy conservation techniques in order
to improve her occupational performance, increase role competency, and enhance overall
quality of life and well-being.

GOALS

1. In 4 weeks, Client will independently manage her medications.

1a. In 2 weeks, Client will take daily medications with 1 VP or less through strategy use.
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1b. In 3 weeks, Client will go 3 or more consecutive days without missing a medication
dose through strategy use.

2. In 4 weeks, Client will independently complete morning routine by using compensatory

strategies and AE.

2a. In 2 weeks, Client will complete shower routine with min. asst. using compensatory
strategies and AE.

2b. In 3 weeks, Client will complete toileting with SBA for transfers and managing
clothing.

Vanessa Russell

April 7, 2020