Tayler Stokes

Date of Assessment: 3/30/21

Name: Client

Diagnosis: R hemisphere TBI

Background Information

The client is a 30-year-old female who experienced a R hemisphere TBI in an MVA. She was
recently discharged from inpatient rehab and is being referred to Home & Community Rehab with visits
3x/week for 4 weeks. The client’s inpatient therapist reported the following: The client can transfer to
and from her wheelchair to the toilet and bed with CGA but requires min assist to manage clothing
during toileting. She can independently complete morning grooming and dressing when she puts on
pullover shirts, sweatpants, and slip-on shoes. She can shower with min assist from a shower bench. The
client still has some active movement in her L side including her L UE, but she tends to not use it during
functional tasks. Her UE is more affected than her LE and trunk. She can walk a few steps with CGA and
use of a four-point cane.

S: The client stated, “I love M&Ms!”.

O: The client was seen 3/25/21 and 3/30/21 for a comprehensive occupational therapy evaluation,
including an occupational profile interview, an observation of occupational performance during the task
of making a snack, and the following evaluations, Canadian Occupational Performance Measure (COPM),
Fugl-Meyer Assessment UE (FMA – UE), and the Performance Assessment of Self-Care Skills (PASS).

Occupational Profile:

The client worked fulltime as a Human Resource Representative for a large technology company.
She is currently on medical leave and is hoping to return to work in a few months. The client
volunteered most Sundays at a local SNF 1x/week with her therapy dog. The client enjoys hot tubbing,
walking and hiking with her dog, mountain biking, camping, and attends a weekly spiritual group. The
client was married 2 years ago to her husband and together they have 4 children from previous
relationships. Her husband’s children do not live with them, but her 6-year-old son does. The son is
staying with his father until the client finishes rehab. The client’s husband works fulltime as a firefighter
and his work schedule usually consists of 24 hours on and 48 hours off. The client’s husband has taken
over house chores however the client thinks he is bad at them. The client’s husband is currently using
his FMLA benefits and is able to be home with the client. In 3 weeks, these benefits will run out and she
will be home alone with her son while her husband returns to work. This poses a barrier to the client
since she will not have the assistance of her husband once he returns to work.

COPM chart – The Canadian Occupational Performance Measure (COPM) is an assessment that
identifies problems regarding occupational performance, provides a rating of the client’s priorities
relative to those problems, and evaluates performance and satisfaction levels.

Occupational Performance Problems Importance Performance Satisfaction

Time with dog 10 1 1
Return to work 10 3 2
Medication 10 8 8
Hot tub 9 1 1
Shower/dress 8 7 5
TOTAL 4 3.4
KEY: Importance: 1 = not important at all 10 = extremely important

Performance: 1 = not able to do it at all 10 = able to do it extremely well

Satisfaction: 1 = not satisfied at all 10 = extremely satisfied

Occupational Performance Assessment:

The client performed the task of making a cheese and cracker snack. During the task, the client
was directly cued 22 times and indirectly cued 8 times to attend to the task at hand. She handled objects
around her such as lights, knifes, spoons, her dog etc. The client would open drawers or the oven and
started washing dishes when she was directly cued 1 time to wash her hands. During the task, the client
used her R UE to lift her L UE up to the sink to wash her hands and used her L hand to stabilize the box
of crackers. All other tasks were completed with her R hand. While opening the package of pepperoni,
the client used her R hand and teeth to pull the bag open. The client used full AROM of her R UE to play
with the dog, obtain snack ingredients, and in slicing the cheese. The client scooted her wheelchair the
majority of the time by using forward body momentum along with slightly propelling her feet. She used
her R UE once to propel the R wheel of the wheelchair. She bumped into things 13 times. The client did
not open the L fridge door when trying to pull the cheese drawer out and did not close the L fridge door
once she was finished. The client’s environment posed some barriers in that the countertops are too
high, and the stairs have nothing blocking them. The client almost fell out of her wheelchair and
required 2 direct cues to reposition herself.

PASS Chart – The Performance Assessment of Self-Care Skills (PASS) is an evaluation that assesses
independence, safety, and adequacy during the performance of everyday tasks.

Task Independence Safety Adequacy

 Playing Bingo 1 N/A 1
Medication Management 1.83 1 1
Shopping (Money Management) 1.8 N/A 1
Dressing 2.44 2 1
Telephone use 2.86 N/A 2
Key: Items are scored on a 4-point scale, 0-3. A higher score on the assessment denotes better performance.

 0 = unable to complete – 3 = normal performance

PASS Observations

The client completed 5 tasks of the PASS: playing bingo, medication management, shopping
(money management), dressing, and telephone use. The scores for independence, safety, and adequacy
for each task are shown in the chart above. During the bingo task, the client required 2 verbal non-
directive cues, 5 verbal directive cues, 3 gestures, and 1 rearrangement of the environment while she
marked the numbers on her score card. She required 2 verbal non-directive cues, 2 verbal directive cues,
and 1 gesture to call “Bingo”. During the task, the client talked and missed marking numbers on her
score card. During the shopping (money management) task, the client required 1 verbal non-directive
cue and 2 verbal directive cues to select the correct items. She required 1 verbal non-directive cue, 4
verbal directive cues, and 2 gestures to select the correct amount of cash for the items. She required 1
verbal directive cue and 1 gesture to select the correct coupon for the matching item. She required 1
verbal directive cue to pay the correct amount of cash and 1 verbal non-directive cue to identify that the
change returned is wrong. During the telephone use task, the client required 2 verbal non-directive cues
and 1 verbal directive cue to obtain the correct phone number for the pharmacy. The client required no
assistance for the rest of the subtasks. The client was confused by the prescription number and asked 2
unrelated questions during the task. During the medication management task, the client required 3
verbal directive cues, 1 gesture, and 1 total assist to open the first pill bottle. She required 1 verbal non-
directive cue and 3 verbal directive cues to distribute the pills from the first bottle into the correct time
slots. She required 2 verbal directive cues to report the next dose of the second medication correctly.
She required 1 verbal non-directive cue, 1 verbal directive cue, and 1 gesture to distribute the pills from
the second bottle into the correct time slots. She required no assistance to report the next dose of the
first medication correctly or to open the second pill bottle. The client ate the medication (M&Ms) twice
during the task and was given 2 verbal direct cues to stop. During the dressing task, the client required 2
verbal non-directive cues, 2 verbal directive cues, and 1 gesture to don UE garment correctly. She
dressed her R UE first and then had difficulty getting her L UE in the sleeve. She had to remove the
garment and start over. The client required 2 verbal non-directive cues and 1 verbal directive cue to use
her L UE to stabilize the garment while buttoning it in order to button it more easily. The client donned
the hosiery without any cues but took a long time to do so. The client required 2 verbal non-directive
cues, 3 verbal directive cues, 2 gestures, 2 task rearrangements, and 2 demonstrations to don her shoes.
She was shown how to use her L hand to hold the laces while she tied the laces with her R hand. She
required no cueing for all other subtasks.
Fugl-Meyer Chart – The Fugl-Meyer Assessment Upper Extremity (FMA -UE) is a sensorimotor function
evaluation on the upper extremities that assesses motor function, sensation, joint range of motion, and
joint pain in individuals that have had a brain injury.

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 - normal

I. Passive Joint Motion 24/24 - normal
J. Joint Pain 24/24 - no pain
Key: Items are scored on a 3-point scale. A higher score on the assessment denotes greater function.

Section A-C: 0 = none/hyper, 1 = partial/lively, 2 = can be elicited/full/normal

Section D: 0 = marked/>6s, 1 = slight/2-5s , 2 = none/<2s

A: Interpretation:

Based on the results of the COPM, the FMA-UE, the PASS and the observation of occupational
performance during the task of making a snack, the client demonstrates difficulties with the
performance skills of coordinating, enduring, attending, initiating, and navigating through her
environment with her wheelchair. The client’s deficits in attention and enduring through a task affect
her ability to complete ADLs and IADLs. The observation of the client making a snack demonstrates the
client’s poor performance in attending to tasks by her requiring continuous direct cues to sustain
attention, along with her impulsivity and possible unsafe medication management practices shown by
eating the M&Ms used in the PASS medication management task. The client’s scores on the FMA – UE,
the dressing task of the PASS, and observation of her making a snack demonstrate her poor AROM and
coordination of her L UE. While observing the client make a snack, she demonstrated inefficient ways to
move her wheelchair and maintain balance and position. This along with her open staircase pose safety
hazards to the client. The client demonstrated a degree of L-sided neglect when she did not open or
close the L fridge door while gathering ingredients to make a snack along with how she did not
incorporate her L UE while buttoning buttons and tying shoelaces during the PASS. Barriers the client
may face in her environment are that her countertops are too high and that her space is slightly narrow
for navigating her wheelchair causing her to bump into things occasionally. The client also faces the
barrier of being alone at home with her son in 3 weeks when her husband returns to work. The client’s
preferred occupations require the use of two hands and sustained attention during the tasks. The client
has strengths regarding her happy and upbeat personality and ability to get along with easily. She has
the support of her dog, husband, and the joy her hobbies bring her such as spending time with her dog
and hot tubbing which were identified in the COPM. The client is an excellent candidate for functional
rehabilitation as it relates to improving L UE use and AROM, attending to tasks, task completion, and
implementation of safe practices while performing everyday occupations.

P: The client will be treated for 60-minute sessions 3x/week for 4 weeks. Intervention will address
deficits in attention, L UE AROM and use, task completion, L-sided neglect, and safe practices
throughout tasks which interfere with occupational performance in her everyday tasks such as dressing,
medication management along with others. Skilled OT services are required for appropriate grading of
activities that will address the above performance deficits. The client’s complex condition requires
advanced clinical judgement to adjust the presentation of activities that will properly challenge her
while also teach her to generalize strategies beyond the treatment session.

Goals

LTG1: By d/c, the client will complete full body dressing independently with the use of her L UE.

 STG1: In 2 weeks, the client will don a button up shirt independently with the use of her L UE.
 STG2: In 2 weeks, the client will don and tie shoes with min A with the use of her L UE.

LTG2: By d/c, the client will safely manage her medication independently.

STG1: In 2 weeks, the client will complete medication administration tasks using attention
strategies with min A.
STG2: In 2 weeks, the client will correctly take medication using a cognitive strategy with fewer
than 3 direct cues.

Signature: Tayler Stokes, OTS_____

Date: ____3/30/21_______