Client’s name: V.T.

Date of referral: 01/23/20

Date of report: 03/06/20
Date of birth: 6/18/80
Primary diagnosis: Traumatic Brain Injury
Precautions/contraindications: Limited cervical ROM secondary to whiplash
Reason for referral to OT: Deficits in short term memory, planning/organizational skills, and
sleep hygiene, and inconsistent functioning
Therapist: Eva Fish, OTS and Corinne Buffo, OTS

S: “It [vestibular symptoms] doesn’t prevent me from going out anymore.”

O: Client was seen in occupational therapy for 60 minutes, 1x/week, for 8 weeks. His vestibular
symptoms were addressed using functional activities and a HEP. Therapy sessions focused on
cognitive strategies for scheduling and planning, as this was one of the client’s main goals.

PDT: Client completed the Professional Development Tool (PDT) a measure to assess the
client’s satisfaction with treatment. Client reported being very satisfied with the therapy
experience and reported only positive benefits.

COPM: Client completed the COPM, a semi-structured interview identifying client priorities and
perceived performance and satisfaction of current occupations during initial evaluation (pre) and
again during discharge planning (post). The following scores were provided:

OCCUPATIONAL IMPORTANCE PERFORMANCE SATISFACTION

PERFORMANCE
PRIORITIES

Pre Post Pre Post

Sleep and bedtime 8-9 2 6 2 6

routine

Planning/scheduling 7 5 7 7-8 8

Coordination 6 5-6 7 3 8
(vestibular)

Use of public transit 6 0 7 5 10

Cleaning schedule 5 7-8 5-6 5 7

 Goals Initial Performance Ending Performance

LTG1: Within 6 weeks, the
client will effectively and
independently utilize
cognitive strategies to plan
and execute a weekly
schedule.
- Client often did not plan Able to do so, much better
ahead for his week, missed
tasks, and felt as though he
was letting tasks pile up until
the last minute and
procrastinating

STG1.1: Within 2 weeks, - Client did not use public Able to use public transit to
client will independently use transit and was unaware of get where he needs, about
public transit to access how to navigate public transit 1x/week to get to SLC.
desired areas in the apps and schedules
community, 4 times per week.

STG1.2: Within 4 weeks,
client will independently
prepare for sleep by 11 PM
through the use of a bedtime
routine and proper sleep
hygiene.
- Client typically fell asleep Has made progress, but still
around 1 or 2 in the morning, going to bed later. Does it
and woke up throughout the about 60-70%.
night, getting on his phone
when this occurred. Client
was hesitant to wear his
CPAP machine and often
scrolled on his phone before
bedtime.

LTG2: Within 6 weeks, client
will independently report
missing 1 or less scheduled
daily tasks as a result of
improved vestibular
symptoms.
- Symptoms occasionally Not interfering with daily
prevented client from going schedule anymore
out in the community and
working. No strategies to
prevent symptoms were
known.

STG2.1: Within 2 weeks, - No vestibular exercise were Client is now incorporating

client will report having one known; symptoms vestibular exercises into daily
or less weekly disturbances to occasionally prevented client routine, performing exercises
occupational performance due from accessing the nearly every day
community
to incorporating vestibular
home exercises 1x/day.

STG2.2: Within 4 weeks, - Any task involving moderate Vestibular symptoms not
client will complete dynamic to large head movements interfering with cleaning
cleaning tasks with 1 or less stimulated symptoms tasks.
reported vestibular symptoms.

A: The client made good progress in therapy and completed 5/6 of his short and long term
goals. Client did not complete his goal of going to bed by 11pm, but has made great progress
towards this goal and utilizes his bedroom routine approximately 65% of the time. Client now
uses external strategies to plan and execute a weekly schedule and has improved his ability to
complete weekly tasks and errands. Due to inconvenient bus schedules in his home town, client
is only using public transit when he needs to travel to Salt Lake City. However, he has improved
and is more confident in his ability to plan and navigate public transit. Client has shown drastic
improvements in his vestibular symptoms, and is able to incorporate vestibular exercise
movements into cleaning and other IADL tasks. He no longer misses scheduled tasks due to
symptoms.

P: The client will continue to utilize cognitive strategies learned in occupational therapy. To
promote continuity, he will continue to utilize a nightly bedtime routine checklist, daily vestibular
exercises, and daily planner to organize tasks for the week.

Signature: Corinne Buffo Date: 3/6/20