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EVALUATION NOTE

DOB:L/22/1957

Name: D. N.

6ender: Female

Date of Report: 2/6l20LG

Primary d iagnosis/condition: Trau matic brain inju ry

Therapist:

Cou

rtney McDonald

2{h,2013, client was in motorcycle accident which resulted in a traumatic brain injury and
extensive fractures throughout her body.
Hx: On

JuJy

Client reports that she feels like she is doing very well in all areas of her life. She reports that her
abilities have improved over the year. For example, she no longer needs a cane to waik.
S:

0: Client was seen on L/28 and 2/4 for

a comprehensive occupational therapy evaluation due to

caregrver concerns about cognition. The Canadian Occupational Performance Measure {COPM), an
^h-eervation of occuoational oerformance. the Patient Competencv Rating Scale (PCRS), and Weekl_v
Calendar Planning Activitv {WCPA} were administered.

Occupational Profile
The client is currently seeking services to work towards her goals of renewing her license as a registered
nurse so she can return to work, improving her balance, and being able to independently plan meals.
She currentlv feels that she is successful in her ADLs. She needs help with her lADLs, such as meal prep,
and work participation. Her main barriers are decreased short term memory: poor problem solving

-accord^nq
bi*' '
skills. She

abilities, difficulties with time management, lack of insight, and inadequate social interaction
struggles with controlling her emotions and cries when she is frustrated. She has a very supportive
farrriiy. She has a caregiver with her at all times. She participates in several group activities, such as book
club and yoga/stretching classes. She used to be a registered nurse in obstetrics. She wants to return to
work as a nurse and specialize in lactation. She is hoping to obtain her driver's license soon so that she
may be more independent and more likely to be able to return to work. She currently relies on others
for transportation. Client and caregiver report that she is independent in her ADLs, preparing simple
meals, doing laundry, and completing household chores.
COPM
The COPM is a standardized criterion-referenced assessment. Using the COPM, an interview is

conducted to assess the client's occupational priorities. This information is used to establish goals. The
COPM will be administered at discharge to track improvement in performance in and satisfaction with

occupational priorities.
Occu p ati o nal Performance Problem

lmportance

Performance

Satisfaction

Going Back to Work

lmproving Balance

ilifiiiflliltlllf,i

*o

Meal Prep

Iotal Scores
Her top priorities are: going back to work, improvinC

3.3

herHhm,+f,fr?l:;"t

Client reports that her typical day involves waking up, getting ready for the day, and making a breakfast
of something light, such as cottage cheese and grapes. She struggles with picking out her clothing.
During the day, she does some house work. Her main responsibilities are cleaning the floor and
bathrooms. Throughout the week she goes to a variety of appointments and events. Client stated that
she goes to individual therapy (which her caregiver clarified as speech therapy) which includes a book
club that focuses on cognition, and yoga and stretching classes a couple of times a week. She uses a
planner to keep track of appointments and a list of household chores. For lunch and dinner, she usually
eats food that is premade, microwavable, or does not need to be cooked. She does some grocery
shopping and uses a linear searching method to locate iterns on the shelf. Throughout the day, she
studies for her driver's license exam and takes continuing education courses for nursing so that she can
renew her license. She has a difficult time staying awake past 5:00 p.m. unless there is a television show
she wants to watch or an event later in the evening.

Observation of occupational performance

During the assessment of occupational performance, client was observed making a tuna fish sandwich.
She independently walked to the fridge, collected food items for the sandwich, and assembled the

sandwich. She asked for utensils to make the sandwich but did not make an effort to find them herself,
even when prompted. She placed all of the items near her right side on the countertop. She leaned
against the counter for support. She required min VC for initiation and continuation of sandwich making
activitv.

from a premade mix. Her posture was rigid throughout the activity.
She kept the mixing bowl far from her body. Once again, she asked her therapists to locate missing
items for her instead of searching for them herself. She was independent in measuring ingredients,
mixing, pouring the batter into the pan, maneuvering the pancake, and slicing fruit to be placed on top.
She did not use cognitive strategies that were suggested by her therapists. Throughout the activity, she
kept her body close to the hot stove and forgot to turn it off when finished with the activity.
She was observed making pancakes

During both sessions, the client only initiated a conversation once. At the end of the activity, she was
asked to bring two items to the next session. She needed max verbal p[g1npts when asked three

minutes later what she was supposed to bring.

PCRS

The PCRS is used to assess awareness of deficits in occupational performance in the client. The client fills
out a form rating their difficulty in doing a variety ol occupations [i.e. preparing meals, dressing,
socialization, finances) from l-can't do to 5-can do with ease. A relative or caregiver that knows that

form rating the clienfs ability to perform occupations. The two forms are compared
to assess the level of client's awareness of deficits,
client also fills out

P,r,,eMfAEt$b*

3i

T:akir,l.g:tnre.s-f.p.er.sqnalhygi:en:e

s
4

5
4

Washine the dishes

EOriftg,,tite.:tS

::::4

,,,;.6

N/A

7
e

N/A
v

"*

Dressing self

Takine care of finances

K.eoificlsaoo

ntrr

idlh

Startins eonversation in a srouo

Stbvindrtnts{vsdir+,'

:a

iri3i,:

Remembering what l/they had for dinner last night

*irne$beii*s.na*

2,,

a
a

Remembering mylthei r daily schedule

he nEi

por

fiifiEsltf*hey'
Driving a car if Uthey had to

Rermer

'

, li:.i 6xlllinf

Ctfu.nb

Adjusting to unexpected changes

Hdfidlr'nci8,r

{rEteats thilsanle.j

4
fthe$rk*e$r,:,w,ell

Acceotine criticism from other oeoole

TartH, s.affl|fd(

Acting appropriately when around friends

snqd,ing,

4
4:

oi.

-1

Participating in group activities

something Uthey say or do has upset

:""f"-#iliJhen
Sch ed uli

ng da'rly activlties

Und*,ffieadias'aeiff,
Consistently meeting daily responsibil ities

jest-t.olJibsr

Keeoine from beine deoressed

t,l;i:;E

,t,t.lill,a

-;- t,t.vJ.LPur- +hl:

lrn a-r:
Charra;:anA,H r\uh r\D Lls?+h tiDiur

lrtn nY*^>r6'

l.
o

Keeping emotions from affecting my,/their ability to go about

the daYl5 activities

Controlling laughter

The largest difference in score was with starting conversation in a group. There were large differences in
keeping appointments on time, getting help when confused, accepting criticism from others, and

participating in group activities. The clienfs average score is a 3.6 whereas the spouse's average score
2.9. This is indicative of the client having deficits in awareness of disability particularly in social
situations.

is

Weekly Calendar planning activity

The WCPA is a functionalactivity developed as a cognitive fAOft#Yffi*ine how subtle cognitive
difficulties in executive function influence the abitity to perform muftipfe step activities in daily tffe. The
task involves organizing appointments into a weekly schedule while keep track of multiple rules as the
activity is performed, monitoring passage of time, recognizing scheduling conflicts, and inhibiting
distractions. Error patterns and strategy use are examined as well as accuracy.

all L7 appointments onto the weekly schedule. 14 were entered accurately, 3 had
signfflcant errors. The only strategy she used was to check off the appolntment after she had written it
on the calendar. She started at the top of the list and wrote them on the calendar in order. She did not
read through the entire list before beginning. This strategy was ineffective because some of the fixed
She entered

'

appointments ended up being placed in the wrong time slot due to a different variable appointment was
already scheduled. She was able to inhibit distractions, and keep track of multiple rules as she did the
task. She was supposed to tell the therapist after seven minutes had passed. She did not do this and
when asked about it stated that she thought she was supposed to complete the entire activity in seven
minutes. lt took her a total of 10 minutes to complete.

lotat tlme (mrn

Plannins Time (min

Number of Rules Followed (out of

Number or Total Strategies

Overall, she did very well on this activity. However, she has deficiencies in cognitive strategy use.

When asked follow up questions, she stated that the activity was not difficult for her and that she would
not do anything differently if she were to do the activity again. Ratings ranged from 1 (completely
disagreelto 6 (completely agreel.

t,iiTfiL,td*k#

'

2. I ccmpleted this task without any difficulty

*.i:tlilb*Eififfi:r*'

,iti;;;a,,r."",.
4. I had difficulty keeping track of everWhing I needed to do
5lijlt"dio.'tdi* CIh.E regfiieri'bd
6. I would change the wav I went about this task
These scores indicate the client has lack of awareness in cognitive disabilities.
Environmental assessment
Client is a 59 year old married woman. She used to be a registered nurse practicing in obstetrics.
However, she has been unable to practice due to her TBf. Cfient recently moved to a new home in
Kaysville. She has a lot of social support. Her husband is very supportive. She has caretakers with her at
all times. Her three children provide support when they can. She interacts with friends and receives
support during her speech therapy, book club, and exercise programs.
A: Client demonstrates poor safety awareness in the kitchen due to poor memory. She flipped the
pancake too early due to impufsiveness. Due to her brain injury, she is not aware of some deficits in

occupational performance. Client does not initiate conversation and sometimes requires extended time
to respond. She sporadically uses cognitive strategies to aid in performance. However, these strategies
are often not effective or she abandons them partway through the task. She has gooa ePot&nd fine
motor control. She required the counter for support due to insufficient standing balance and endurance.
Ste5J,r.,F'l
She has good balance while walking and is able to ambulate independently. Although, her gait pattern is
f:tJ.,'-r*t*u'
uneven due to the multiple orthopedic injuries she sustained in the motorcycle accident. She was able
bzB'r +Ia-{"to easily open cans and containers, measure ingredients, and cook the pancakes. The discrepancy in the
PRCS client and spouse ratings indicate that she lacks insight in her social interaction skills.
fvla+-l*-

will be seen for skilled occupational therapy services 1x a week for 6 weeks. Client will be
taught compensatory strategies for problem solving and memory. Her social skills will be addressed due
).
to hergoal of returning to work. rrl'3rt a}tc'r/^
Soi d pal*rAl-vvu
I
P: Client

{'

will independently ask 6/5 predetermined questions during a professional

conversation within L5 minutes.
LTG 1: By discharge, client

three sessions, client will ask 416 predetermined questions during a professional
conversation with min verbal cues.
STG: ln

STG: ln five sessions, client

will independently track time and conclude a 15-minute

conversation.
LTG 2: By discharge,

"T:

clientwill independently plan and

managetim#"ff*f!f f.7"rgrk#tlr"r.

!n three sessions, client will plan three simple meals with mod aErst for the week.

will independently plan each step of a social dinner with accurate

not 6'r.Fe u.:f.."-tJl*-:,'{'-1-^-{"-r.

STG: ln five sessions, client

time

estimation'

to help formulate goals

with the client. This process was difficult due to the client's lack of awareness of her deficits. When
-=-i:+ti about specific areas of her iife that we thought we mieht be able to help her with, her response
was usually that she was doing fine and does not think that she needs help in any areas. Eventually, she
talked to us about the goals she is already working towards. For example, she wants to renew her
license as a registered nurse and specialize in lactation. We agreed on using occupational therapy to
Process of setting goals and plans with client: Christina and I used the COPM

r'.aln hsr ebtain these soals.

Practice Models

outcome of this model is to create optimal congruence between the person, occupation, and
environment. Making changes in the client's environment or the client herself will lead to changes in her
occupational performance. Using this model, we will evaluate the client's personal, environmental, and
PEO: The

occupational supports and barriers to help her achieve optimal performance. Using this model will help
ensure that the client is in the least restrictive environment possible. lt will help the client to learn
strategies to address occupations that she is struggling with. Changes in the client could include
increasing balance and endurance, and learning cognitive strategies. Changes in the environment could
include placing needed items on the countertop so that she does not need to remember where she
stored them. Changes in the occupation could include making simpler meals to reduce the number of
steps and amount of time the occupation requires.
CO-OP: The outcome of this model is

to use a compensatory strategy that aims to acquire skills through

the use of global cognitive problem-solving strategies and domain-specific strategies, encourage
genei"alization to other contexts, and transfer strategies to other skills in order to increase activity
participation, performance, and satisfaction. Using this model, the client will select her own
occupational goals that are meaningful to her and develop a strategic plan. The client will then perform

the occupation. Once she has finished, she will discuss with her therapists how her performance went
and if there is anything that she needs to change in order for her performance to be more effective.
Social participation: The outcome of this model is

to increase social participation to improve

performance in family, academic, and community-based occupations. This would be beneficial for the
client because it would increase her ability to interact with friends and family as well as any future
patients she has if she returns to nursing. Using this model would increase her ability to initiate o/or.ng bJSJ
conversation and respond appropriately. The clienfs interactions with herfriends and family, how she- W*"Jh?
self-regulates, and supports in her social environment will be evaluated. Through the use of an accepting
and safe environment, she will be able to learn socially appropriate behaviors during an intrinsically 1
rewarding activity.
lnterventions:
Treatment #1- Self generated planning activities using client's planner. lmplementing Goal, plan, do
to utilize throughout sessions and for homeworf<.

check strategy

Treatment #2- Use self-generation to determine what she will need to ask in a typical client interview
when she is a nurse. Role play will be used so that she can practice. Then, we will discuss what went
well, what didn't and what to change next time.
Treatment #3- Meal planning activity; grocery shopping activity
Treatment #4- Problem solving activity that includes scheduling and time management. Work on her
professional commu nication skills.
Treatment f5- Meal planning activity

Treatment #6- Reassess and discharge

Evidence f or treatments:

ln order to improve the client's capacity to process information, including increasing learning and
memory,lelf-generalization is used. The generation effect is when items that are self-generated by the
client are'tielnbered better than items provided to them. This process involves having the client setf-

generate steps of an activity they are about to perform. This will be used throughout the intervention
process to help generalize this skill to a variety of situations (Goverover, Chiaravalloti, & DeLuca, 2010).

""1

We will be using the client's identified goals from the COPM. Treatment will revolve around these goals
and will be graded up and down. Challenges and success will be discussed after each activity to help
facilitate self- awareness in our client. Research has shown that this is an effective way to produce selfawareness (Doig, Kuipers, Prescott, Cornwell, & Fleming, zALq,
Finally, we will be teaching social skills to help our client achieve her goal of returning to work as a
registered nurse. Research has shown that addressing communications skills for people with TBI is
effective regardless of the approach (Finch, Copley, Cornwell, & Kelly,20L6).

ors
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References
Doig, E., Kuipers, P., Prescott, S., Cornwell, P., & Fleming, J. l2OL4l. Development of self-awareness after
severe traumatic brain injury through participation in occupation-based rehabilitation; Mixed-

methods analysis of a case series. Americon Journal of OccupdtionolTherapy,64 578-588. DOI:

10. 50

Uajot .zAL4.AtCI7 85

Finch, E., Copley, A., Cornwell, Pl, & Ketly, C. {2016}. Systematic review of behavioral interventions
targeting social communication difficulties after traumatic brain injury. Archives of Physical
M ed i ci n e

o n d R eh o b i I i tafion. DOI

: 10.1O16/ j. apm

r. 2015.

1 1.

005

Goverover, Y., Chiaravalloti, N., & Deluca, J. (2010). Pilot study to examine the use of self-generation
improve learning and memory in people with traumatic brain injury. Americsn Journol of
O cc u pa

ti on a I

Th e ro py,

64 5&

-546. DOI : 10. 50 L4/ ajoL2AL0.09020

to