Occupational Therapy

Progress/Treament Note

Client’s Name: Supervising Therapist: Kristine Barrios OTR/L

Student Therapist: Jen Messer OTS
Date: 11/17/17 Time In/Out: 2:00-2:50pm # Units:
Clients Goals Addressed:
Goal (Target Behavior/Distal Measure) Proximal Measures GAS Scale
(Distal)
1 Within 6 months, Client will Date: 11/17/17 Date:

complete basic self-care tasks (i.e. Self-care -1

brushing teeth, dressing, strengthening hands/fingers, improving
bilateral coordination
grooming) with no more than 2
verbal cues in 4/5 trials in order to
increase participation in ADL
occupations.
2 Within 6 months, Client will Date: 11/17/17 Date:
-1:
demonstrate the needed fine Fine Motor skills
motor skill to color and cut simple strengthening hands/fingers
establishing tripod grasp
shapes from a sheet of paper with
80% accuracy
3 In one year, when given meat or Date: 11/17/17 Date:

vegetables, Client will demonstrate Feeding --1

decreased oral sensitivity by exposure/desensitization to new foods/vegetables

tolerating eating 10 bites over 5

consecutive data collection days
4 In 6 months, Client will Date: 11/17/17 Date:

demonstrate improved balance and Balance -1

motor planning skills in Pacing
Visual Motor Coordination
preparation for riding a bike by Strengthening
completing a complex 5-step Improving
bilateral coordination
obstacle course with no more than
2 verbal cues in 4/5 trials.
Clients Occupations Treated: (check all that apply)
X ADL’s/Self Care: (bathing, showering, toileting & hygiene, swallowing/eating, feeding, Personal device
care & managing personal belongings, personal organization ,functional mobility, personal hygiene and
grooming)
X Instrumental ADLS & Graphic Communication: (Care of others, Care of pets, child rearing,
Communication management, driving & community mobility, financial management, health
management & maintenance, home establishment & management, meal prep & cleanup,
religious/spiritual activities & expression, safety & emergency maintenance/awareness, & shopping &
Handwriting, Keyboarding, Drawing, Coloring, Art, etc).
Rest & Sleep: (Rest, sleep preparation, sleep participation)
Work: (Employment interests & pursuits, Employment seeking & acquisition, job performance,
retirement preparation and adjustment, volunteer exploration & participation).
X Play & Social Participation: (Social Awareness, Building/Maintaining Relationships, Turn-taking,
imaginative play, sharing materials, exploring new play ideas/opportunities, play exploration, social
participation in community, family and with peers)
Leisure: (Leisure exploration & participation)
Client Factors & Performance Skills addressed: (check all that apply)
 Occupational Therapy
Progress/Treament Note

Motor/Muscle/Movement Sensory Skills Social Skills

Skills
X Core X Manipulation Temperatur Pressure Engages/Approaches Others
Stability e
X Endurance X Coordination Hearing X Taste Concludes/Transitions/Takes turns
X Position/Alig X Motor Vestibular Smell X Communicates (verbal/non-verbal)
ns Planning
X Joint Mobility X Reaching/gr X Tactile Pain Looks/Turns (Makes eye-contact)
asp X
X Joint Stability Reflexes Propriocepti X Visual Emotional Expression
ve
X Tone & X Controlled Discriminati Modulati X Physical behavior (regulates
Strength Movement on on movement, position, touch)

Other Other Other

Processing/Cognitive/Mental functions: Visual Perceptual/Visual Motor Skills
X Attends Experience of self & Oculomotor Skills Object Perception
time
Memory X Emotional X Visual Attention X Eye-hand
regulation Coordination
X Sequences Tasks Energy & drive Visual Discrimination X Copying Shapes
Executive Functions X Notices/responds to Visual Motor Speed Spatial Relations
cues
X Chooses/Uses X Pacing of activities Visual Memory Form Constancy
materials
X Locates/Gathers X Organizes Materials Depth Perception Visual Acuity
materials
Adjusts/Accommodate X Navigates Visual Closure Sequential Memory
s Environment
Initiates/Continues/Ter Orientation to self, Figure Ground Visual Closure
minates other, time & place
Tasks/Activities
Other Other
Session Data
(S)
Subjective Data (Home Progress/Comments):
“He is really sleepy, I wish you saw him when he wasn’t sleepy he is a different person.”

Objective Data (ratio: #correct/ # trials and % accuracy, count: # of occurrences in a time frame, # min on task, etc.)

Progres M: Mastered (>80%) GP: Good Progress (60-79%) P: Progress (40-59%) E: Emerging (<40%)
NA: Not Addressed
s
Assist I: Independent MinA:75% ModA:50% MaxA:25% Dep: Dependent - 0%
Prompt S= spontaneous (w/o request) I= Independent (w/request, no other prompt) VP= Verbal Prompt M= Model (imitation)
R=refused/unable
(O) Intervention Description and Objective Performance Data
 Occupational Therapy
Progress/Treament Note

Client was seen at the Life Skills Clinic for skilled therapy services and arrived awake to therapy session.
Client had hands over his ears when student therapist walked out to greet him. Client transitioned to gross
motor room with multiple VP from student therapist. Client transitioned to next task with M from therapist
to complete 5 step obstacle course. Client showed increased strength and balance when using Bosu ball,
as well as independently utilizing scooter to move around room. Client completed obstacle course 3x with
VP from student therapist to complete task with a break being implemented after completing course. Client
transitioned to Boom Whackers for a 1 minute break and transitioned to next task with one VP from
therapist and sound of timer to aid client in transitioning between tasks. Client completed coloring activity
with therapist, switching between left and right hands multiple times as well as resting his crayon in the
right hand without fully grabbing the crayon from his left hand. Client spent time with therapist at tabletop
task coloring for 10 minutes without a break and getting up from table one time to go to the trampoline.
After VP from grandmother client requested break from therapist and jumped on the trampoline for 1
minute and then transitioned back to task to cut out coloring activity. Client required Mod A to cut out
paper with left hand after initially grabbing scissors with his right hand and transitioning to left hand with
his thumb flipped while holding the scissors with only 2 fingers. Client required multiple VP as well as Max
to readjust scissors to cut paper. Client also required VP to stop and not cut out the middle of the picture,
and to VP to follow the black lines on the paper. Client completed task and transitioned to taping the
picture onto the wall to engage in a multi-step task. Client required Mod A to place tape on the back of the
picture with M from therapist 2x. Client transitioned to next task of a break with the I Spy game for 1
minute in order to transition and cool down to go home with grandmother. Then Client transitioned to
cleaning up with VP from therapist to attend to task and VP from grandmother as well. Client was able to I
place coat on his arms without assistance from grandmother or from therapist. Client was able to transition
to going home with I from therapist to take picture home.

(A) Assessment

Client showed progress in completing tasks with decreased verbal prompts from student therapist
to engage in tasks. Client showed increased coordination through use of the scooter while laying
prone as well as sitting to move throughout the space. Client demonstrated increased core strength
in ability to balance on Bosu ball with min A needed from student therapist. Client also
demonstrated increased attention to task with spending 10 minutes on coloring task with therapist
without getting up from table or needing to take a break. Client demonstrated difficulty with
completing coloring task using only his left hand as he switched to his right hand multiple times and
would rest the crayon in his right hand for a second and then transition back to using his left hand
to continue coloring. Client also showed progress in being able to color much of the page as well as
crossing midline. Client was able to cut out the paper with increased attention to the cutting task
but demonstrated less focus on following black lines of paper. Client was able to follow directions to
tape picture after modeling from therapist multiple times, as well as verbal directions to tape the
picture together. Client was able to transition back to tasks after a 1 minute break using a timer,
and did not require multiple prompts from therapist, showing progress in ability to transition and
follow directions.

(P) Plan
Continue skilled occupational therapy services for 50 minutes each week, 1 time a week. Continue
implementation of non-preferred food textures during therapy sessions as well as tasks that require
use of fine motor skills. Client continues to struggle with using his left hand consistently, and it
would be beneficial to continue to implement ways for client to use his left hand in tasks and to
 Occupational Therapy
Progress/Treament Note

cross midline as well. It would also be beneficial to continue to work with client on tying shoes as
his mother expressed that the client has a strong desire to learn how to do this task. Next sessions
will focus on motor tasks required for tying shoes as well as fine motor tasks focused on increasing
hand strength and use of left hand.
Home Program: Gave grandmother instructions and ideas about continuing to help client with utilizing
his left hand during cutting and coloring tasks, and to try and observe when client is switching his hands.
Family/Care Giver Education: - Verbal - Written - Demonstration
-Homework Sent
Family/Care Giver Understanding of Education: -Verbal -Demonstration

x Continue Dischar Other: Next Appointment:

ge
Student Therapist Signature:
Supervising Therapist Signature: