Occupational Therapy Evaluation Report and Initial Intervention Plan

Clients name or initials: XXX

Date of referral: 1/25/17
Date of Report: 1/25/17, 2/1/17
Date of birth and/or age: 2/19/68, 49 y/o
Primary intervention diagnosis/concern: Acquired Brain Injury (Memory deficits)
Secondary diagnosis/concern: N/A
Precautions/contraindications: Asthma, Hay fever, Cancer – tonsils
Reason for referral to OT: Independent Living Skills
Therapist: Caitlin Winters OTS

S:

Client was friendly and seemed to look forward to the sessions. He referred to his condition as

“stupid aneurysm” multiple times, and said “I’m sorry” often for not remembering things. He

was discouraged at times throughout the standardized assessment.

O:

Client was seen January 25th and February 1st for comprehensive occupational therapy

evaluation. The following assessments were administered:

Results:

Canadian Occupational Performance Measure (COPM): The COPM is a semi-structured

interview that identifies the client’s occupational priorities for intervention.

Priorities Importance Performance Satisfaction

1= low importance 1 = I’m terrible at this 10 1 = I’m not at all satisfied
10= high imporance = I have no problems with my performance
performing this 10 = I’m totally satisfied
Participation in Leisure 7 3 0
Activities (Hobbies)
Community Mobility 7 3 0
(Transportation)
Work (Volunteer) 7 0 1
 Rivermead Behavioral Memory Test Third Edition: The RBMT-3 is a formal assessment

that examines aspects of verbal, visual, spatial and perspective memory, orientation/date, and

new learning.

Sum of Scaled Scores 56

General Memory Index 58

Percentile Rank .3 percentile

Confidence Interval 48-69

Overall results from the RBMT-3 indicate that Client falls well below average on the

assessment indicating a significant memory deficit. He did achieve high scores in picture

recognition (63rd percentile) and delayed recall of his belongs (25th percentile). All other subset

scores fell at 9% or lower. Client scored the lowest in the area of perspective memory, scoring

<1 percentile for all subtests within this area.

Occupational Profile:

History:

Client is a 49-year-old male who is seeking services due deficits in short term memory

secondary to an acquired brain injury from brain aneurysm, which occurred over 12 years ago.

Prior to this incident, Client worked full time in construction management and enjoyed

mountain biking, jet skiing, and other outdoor activities. He lived alone, was able to drive with

no problems, and was independent in all of his ADLs and IADLs. He previously enjoyed going to

the gym near his apartment, but it recently closed. After his brain aneurysm, Client was moved

to a care center, which he did not enjoy, and now resides in an apartment with his mother.
Current Occupational Performance:

Client reports that his days are fairly unstructured due to his lack of responsibility. He

explained that since his accident, his concept of time has been disoriented which effects his

ability to grasp what day/month/year it is. He wakes up in the morning and spends much of his

day watching television, or will ride the bus to go to different restaurants in the Sugarhouse

neighborhood of Salt Lake City. Client reports that he prepares simple meals, does dishes, and

laundry around his house. He has no problems with getting ready in the morning. Client is no

longer able to drive himself anywhere due to safety concerns following his aneurysm. He rides

one bus route on a regular basis to get to his favorite restaurants, and walks across the street to

grocery shop at a nearby Walmart. He states that although he has a large network of friends, he

often times does things by himself. His interests include going to rock concerts, eating out at

restaurants, playing solitaire, and hiking when he can. His roles include being a son, brother,

friend, and music lover. His priorities for therapy include engaging in preferred hobbies, getting

around on the bus outside of his one typical bus route, and getting back to work or

volunteering. Client was able to remember important future dates such as his 50 th Birthday and

a concert he is looking forward to in August.

Context:

Client lives with his older mother in an apartment in Murray, UT. He is able to navigate

in and to familiar environments such as his home, neighborhood, and Dee’s Restaurant. He

claims that he has a codependent relationship with his Mom and a large network of friends in
the Salt Lake area. Client has a sister who lives in Florida, and a niece that lives in Portland, OR.

He enjoys keeping up with current affairs and is of low SES.

A:

Interpretation:

Strengths and areas in need of intervention

 Client’s strengths include being very outgoing, taking one familiar bus route, having a

vast network of friends, intact physical mobility, using social media, and taking notes on

his phone. He is able to utilize an iPad to help remember scheduled appointments. He

also demonstrated that he was able to remember things that were extremely important

to him such as where his watch and phone were hidden. In addition, Client is compliant

when asked to perform tasks during treatment and actively engages with the therapists

during the sessions. He has a great sense of humor and is open and willing to talk about

his experiences.

 Areas in need of intervention include his poor memory, poor balance, inability to

participate in previously enjoyed hobbies, forgetting where he is going if distracted on

the bus, and taking vague notes on his phone. Client often times misplaces his phone

and iPad around his house. He seemed discouraged when taking the memory

assessment and apologized often for not remember things, which may be a sign of

psychosocial concerns. Although Client reports that he uses his iPad calendar to record

appointments, he does not know how to set a reminder alarm that would be useful in

helping him to know what he is supposed to be doing.

Support and Hindrance to occupational performance

 Client is supported by his mother, friends, access to a simple bus route, and ability to

connect with people via his phone and social media. He is also supported in the fact that

he is relatively young and willing to seek services to enable his occupational

performance. As shown by his performance on the RBMT-3, he is also supported in the

fact that he can remember very valuable objects, and has average visual memory. Client

is able to remember meaningful future dates and important belongs, which may mean

that the value of the information which he needs to retain plays an important role in his

ability to remember them.

 His barriers to occupational performance include an inability to navigate unfamiliar

environments or complicated bus routes, learning new things, remembering names,

small details, and what he is supposed to be doing. During the assessment it was made

evident that Client struggles immensely with orientation and knowing what

day/week/month/year it is. It was also made clear that he cannot remember verbal

information and spatial routes that were more than 3 or more steps that were taken

around the room. These could greatly affect his ability to engage in occupations such as

following a bus route, or taking verbal directions from a supervisor. He scored

exceedingly low in the area of perspective memory, which is his ability to remember to

perform an action or recall a planned activity in the future. This could be a major

contributing factor in his lack of engagement in many activities such as outings with

friends, or job interviews. Although he is able to use technology to record messages, he

 does so in a way that is vague and ineffective in cuing him to remember important

information, such as writing a note that is only one word.

Prioritization of Need Areas:

Client’s ability to engage in meaningful occupations is greatly impacted by his lack of

prospective, verbal and spatial memory and his deficits in new learning. These characteristics

are evident by extremely low scores in these areas on the RBMT-3. As Client received much

higher scores in visual memory and was able to remember very valuable objects during the

RBMT-3, we will attempt to incorporate these supports into his treatment and provide

strategies that target these areas.

As obtained through the COPM, client’s priorities for therapy include engaging in preferred

hobbies (going to the gym), getting around on public transportation outside of his one typical

bus route, and returning to work or volunteering. Due to the client’s short length of stay, we

will focus his priorities on increasing public transportation usage and ability to engage in

preferred hobbies. These two areas necessitate many foundational skills and can be transferred

to other occupations in order to enhance overall performance.

P:

Mutually Agreed on Long-Term Goals:

1. Within 6 sessions, client will independently take a multi-bus route to get to an

appointment using compensatory strategies.

2. Within 6 sessions, client will independently participate in one previously enjoyed activity

outside of his home using compensatory strategies.

Mutually Agreed on Short-Term Goals:

1a. Within 2 sessions, client will independently identify a bus route to a non-familiar

location using a transportation app on iPad.

1b. Within 4 sessions, client will independently take an unfamiliar single-bus route to an

appointment using compensatory strategies.

2a. Within 4 sessions, client will independently demonstrate the use of one external

memory strategy to keep an appointment.

2b. Within 4 sessions, client will independently utilize phone applications to complete two

daily activities.

Recommended intervention methods and approaches:

Client would greatly benefit from skilled occupational therapy (OT) services in order to

address his memory deficits and enhance his occupational performance. Therapy services will

focus on teaching compensatory strategies such as mnemonics, imagery, translation and

attention to doing, to address his memory skills and increase his ability to engage in meaningful

occupations. Approaches to therapy will include establishing new skills and modifying tasks to

overcome his memory deficits. We will also provide Client with strategies to employ external

memory strategies such as timer applications on his cell phone, shopping lists, and daily

checklists. We would also like to prevent Client from any further occupational decline such as

lack of participation in leisure activities or home management.

Scientific Evidence

According to research conducted by Toglia, Rodger, and Polatajko (2012), effective

cognitive strategies to address memory deficits include rehearsal, mnemonics, rote scripts,
association, imagery, elaboration, translation. In this same article, the authors also discuss the

effectiveness of list making and attention to doing. The strategies we will be using to address

Client’s memory include mnemonics, imagery, translation, list making, and attention to doing.

We chose to focus our interventions around teaching Client memory strategies based on

recommendations from this article, his results from the RBMT-3, and his personality and

interests.

Broad Model and Justification

We will formulate our interventions with Client based on the foundational model of

Person, Environment, and Occupation (PEO). The overarching outcome of this model is to

increase the congruence between these three areas in order to enhance the client’s

occupational performance. By understanding Client’s current memory capacity and where it is

breaking down (P), the required components of the occupations that he is required to perform

every day (O), and how his environment either helps or hinders his performance (E), we can

increase his ability to engage in his desired activities. As we already have a better

understanding of Client’s current memory strengths and deficits, we can now engage in task

modification, and environmental adaptations to help support his occupational performance.

This theory states that change occurs through making environmental modifications to enhance

performance, understanding the person as a dynamic, motivated, and ever-developing being,

and by understanding the transaction between each of the components with one another

individually and as a whole.

Complimentary Model and Justification

We will also incorporate the Cognitive Orientation to Daily Occupational Performance

(CO-OP) into our treatment sessions. We felt that this was a good choice for treatment based

on the fact that this model is helpful in teaching Client how to accomplish tasks by utilizing the

GOAL-PLAN-DO-CHECK approach. This will help him develop problem solving skills, utilize

guided discovery and independence, and promote learning and generalization by providing

positive reinforcement to acquire new skills. This model states that change occurs through the

dynamic interaction between client chosen goals, performance analysis, cognitive strategy use,

guided discovery, enabling principals, significant-other involvement, and intervention format.

The interaction between these components lead to skill acquisition, strategy use,

generalization, and transfer.

Expected frequency, duration and intensity: 1x per week, 1 hour/session, 6 sessions.

Location of intervention: University of Utah Dept. of OT/RT, Treatment Room

Anticipated D/C environment: Home

Signature and Date: _____________________________________________________________