Reason for Services
What brain injury did Sam experience?
Traumatic brain injury with subdural hematoma after a hit-and-run accident.
What was Sam’s job before the injury?
Auto mechanic.
Who is Sam’s primary caregiver during rehab?
His wife, Ingrid.
What is Sam’s cognitive state at Level IV?
Confused, agitated, lacks purposeful goal-directed behavior.
What is an appropriate short-term goal for Sam?
Participate in 2–3 structured activities with minimal agitation.
What procedure was done to save Sam’s life?
Emergency craniotomy.
Name two leisure activities Sam enjoyed.
Watching movies and taking walks with his wife.
Where did Sam live before his injury?
Single-level, two-bedroom home in a rural town.
What type of communication might Sam display at this stage?
Incoherent or inappropriate verbalizations.
What behavior management goal would be critical?
Use coping strategies for agitation with maximal assistance.
What is Sam’s current Rancho Level?
Level IV: Confused–Agitated.
What religious activity was part of Sam’s weekly routine?
Attending church.
What support system does Sam have besides his wife?
Niece, nephew, church friends, and work colleagues.
What motor behaviors are common in Level IV?
Frequent, purposeless movement.
What is a realistic ADL goal for Sam now?
Tolerate assistance for grooming and dressing tasks.
What is a major OT focus at this stage?
Managing agitation, promoting safety, and environmental modification.
How might pre-injury interests influence therapy now?
Incorporating familiar routines to support orientation and comfort.
How does Ingrid’s work situation impact care planning?
She took time off work to stay with Sam during rehabilitation.
How does agitation affect Sam’s ADL performance?
Requires maximal assistance for all basic ADLs.
Why is caregiver training important at this stage?
To manage safety and support structured engagement at home.
Why is structured routine critical for Sam at Level IV?
It reduces overstimulation and promotes more predictable behaviors.
Why is it important to recognize Sam’s prior independence?
To set realistic expectations for recovery and motivate therapy engagement.
What environmental adaptations might help Sam now?
Low-stimulation environment and supervision for safety.
What strategy can help reduce agitation?
Providing simple, familiar tasks with limited demands.
What longer-term goal should be kept in mind?
Gradual reintroduction of meaningful activities as agitation decreases.