Training Material: Sample Subject
Please complete the GOS at admission, discharge, and follow-up for
this sample subject.
is a 32 year old white female. Patient was involved in a MVA on
October 24, 1993 when she was a passenger in the rear seat of the
car. The car was rear ended by another car traveling approximately
50 m.p.h. The patient had no loss of consciousness, and she was
noted to be awake and combative on the way to the hospital. Upon
arrival at the ER the patient was noted to be agitated and confused,
speaking in word salad pattern with global aphasia.
On the day of transfer to rehabilitation, the patient was noted
to be independent in eating, tolerating a regular diet well, independent
in grooming and dressing. She required supervision in bathing secondary
to poor balance. She was independent in toileting, continent for
both bowel and bladder. She was able to get on and off most surfaces
independently, however, required a shower bench for bathing secondary
to decreased balance.
was ambulating at least 50 feet including walking up and down a
flight of stairs with supervision only. She required assistance
in planning any transportation needs. Once she received help in
planning, she was able to pursue the activity independently.
patient still suffered from receptive aphasia, however, could understand
basic directions and conversations most of the time without help.
She spoke slowly but clearly consistently, and needed help to express
her daily needs only occasionally.
physical examination the patient presents as a well developed, white
female who is alert and cooperative, and in no acute distress. Patient
has been cooperative with the staff and other patients, however,
demonstrates some minimal anxiety and frustration when confronted
with new situations. She has difficulty living with her limitations,
but is willing to explore new ways of adapting to her disability.
Prior to the injury the patient was employed as a bookkeeper. At
present she is unable to calculate serial 3's and 7's, has poor
abstraction skills, and is very concrete.
observation the patient was able to seek alternatives involving
basic daily problems most of the time, requiring help only during
stressful or unfamiliar conditions. She has difficulty remembering
routine events and people. She is able to identify 9 out of 10 faces
or events without assistance.
is oriented to person, time and place but requires cues for her
present circumstances. Throughout the examination the patient was
noted to be easily distracted and required frequent cues (every
1/4 hour) to return to activity.
Discharge Date: November 17, 1993
At discharge patient was noted to be independent in all self care
activities including bathing and mobility items with the exception
of community mobility. After a driver's evaluation recommendations
were made for the patient to abstain from driving secondary to cognitive
deficits and impulsivity. It was further recommended that the patient
check with another person regarding plans prior to acting on transportation
noted in following areas:
is now able to understand written and/or auditory communication
without difficulty, demonstrating only occasional difficulty with
selective abstract information. She speaks with a clear and well
modulated voice, again, has occasional difficulty with work finding
in selected abstract discussions.
reading and writing skills have improved significantly. She appears
to completely understand complex ideas and is able to write clearly
and legibly with no more than average errors.
patient has shown decreasing agitation and restlessness with improvement
in concentration. She responds positively to constructive feedback.
patient occasionally exhibits depression, anxiety or frustration
and actively seeks to compensate when faced with some of her limitations.
is recommended not to return to work for approximately 3 to 6 months,
and that she receive speech therapy and occupational therapy to
address some high level work skills and pre-vocational skills. However,
the patient feels that she is able to return to work in a much shorter
patient is actively participating in high level self care tasks
requiring cues only rarely for complex tasks such as balancing her
check book. She continues to have difficulty remembering routine
requests and familiar names. She is able to compensate by utilizing
her memory book and other strategies consistently. She is oriented
x 4 without cues, however, continues to be easily distractible.
Her attention can be as much as 30 minutes per task then requires
cues for redirection.
recommendations for the patient are that her sister and boyfriend
assist by daily phone contact initially after discharge.
Date: May 12, 1994
The patient was seen and examined at the outpatient clinic on this
date. She was discharged from the comprehensive rehabilitation program
in November, 1993. Presently, the patient is independent in all
of her self care activities. She has a valid driver's license from
the state of California. She has successfully resumed her social
life. Patient recently obtained employment working for a business
in which her duties include client and office personnel interaction
and planning and communications skills. She states that she has
been very frustrated in the first week of work because she is unable
to understand much of the complex information, and has mild word
finding problems. Patient also noticed that she had difficulties
in sustained concentration, and learning and memory for new information.
present plan is to continue orientation and attempt to maintain
her present job with the understanding that if she is unable to
compensate in her present work, she will refer to the Department
of Rehabilitation for assistance.
to answer sheet.