Occupational Therapy

Progress/Treament Note

Client’s Name: Supervising Therapist: Kristine Barrios, MOT,

OTR/L
Student Therapist: Alexa Holguin, OTS
Date: 11/03/17 Time In/Out: 11:17-12:05 # Units: 4
Clients Goals Addressed:
Goal (Target Behavior/Distal Measure) Proximal Measures GAS Scale
(Distal)
1 Within 6 months, Client will independently dress Date:
1.attention
Date:
Self dressing
and undress by manipulating and engaging all
 Accuracy of buttoning -2
buttons and zippers on clothing items in 4 out of  Orienting clothing in the appropriate
5 opportunities as measured by therapy data in direction
order to improve self-dressing skills and  Level of assist
participation in school and home occupations. 2. duration for task completion
 time
3. fine motor coordination
 level of assist

2 Date: Date:
-2
Within 6 months, Client will independently form
1.mature tripod grasp
all capital letters and numbers 1-5 utilizing a  level of assist/prompts/adaptation
mature grasp correctly in at least 4/5  type of grasp used
opportunities as measured by therapy writing  duration utilizing mature grasp
samples in order to improve his handwriting 2.duration of task completion
skills needed for increased participation in  time
3. fine motor control
school occupations.  level of assist
 # of letters correctly formed
3 Date:
1.level of engagement
Date:
Within 6 months, Client will attend to a non-
 time -2
preferred fine motor task for at least 5 minutes  accuracy
with minimal redirection and verbal prompts in 4  # of breaks needs
out of 5 opportunities as measured by therapy  level of assist
data, in order to improve fine motor skills and
participation in ADL’s and IADL’s in home and
school settings.

4 Date: Date:

5 Date: Date:

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,
 Occupational Therapy
Progress/Treament Note

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)
Motor/Muscle/Movement Sensory Skills Social Skills
Skills
X Core X Manipulation Temperatur Pressure Engages/Approaches Others
Stability e
X Endurance X Coordination Hearing Taste Concludes/Transitions/Takes turns
X Position/Alig X Motor X Vestibular Smell Communicates (verbal/non-verbal)
ns Planning
Joint Mobility X Reaching/gr X Tactile Pain Looks/Turns (Makes eye-contact)
asp
Joint Stability Reflexes X Propriocepti Visual Emotional Expression
ve
Tone & X Controlled Discriminati Modulati 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 X Object Perception
time
X Memory x Emotional X Visual Attention X Eye-hand
regulation Coordination
X Sequences Tasks X Energy & drive X Visual Discrimination X Copying Shapes
X Executive Functions X Notices/responds to X Visual Motor Speed X Spatial Relations
cues
X Chooses/Uses X Pacing of activities X Visual Memory X Form Constancy
materials
X Locates/Gathers Organizes Materials X Depth Perception Visual Acuity
materials
Adjusts/Accommodate X Navigates Visual Closure Sequential Memory
s Environment
 Occupational Therapy
Progress/Treament Note

Session Data
(S)
Client reported that he cut out a Halloween haunted house all by himself at preschool earlier
this week.

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
Client was seen at the life skills clinic for one hour to work on fine motor and visual perceptual deficits
needed for school and home occupations. Client participated in a motor planning and bilateral coordination
warm up activity which required him to walk heel-toe to locate fabric cut-outs (pizza toppings) on a tape
maze while maintaining his balance. He required Max VP to initiate the task and heed instructions, but he
was able to independently locate all of the shapes and secure all 7 of the fabric cutouts onto the button
pizza. He also participated in various fine motor activities including: tracing, coloring, cutting, and grasping
(with tongs to locate Halloween objects hidden in a sensory bin). During these fine motor activities Client
required frequent breaks, max VP for task completion, attention, and accuracy (cutting on the lines) in
addition to moderate physical assistance to maintain an appropriate grasp while cutting.
(A) Assessment
Client demonstrated higher levels of distractibility and inattention than prior weeks, which could be due to
the new clinic environment and a 2-week gap in OT visits. Despite this, Client has made great progress
towards his dressing goal, as he was able to independently manipulate all 7 fabric cut-outs onto the button
pizza (with varying button sizes) with patience, determination, and a positive affect.
During the cutting task, Client appeared fatigued when he was halfway through cutting out the second jack
o lantern Halloween mask, and the activity was graded down by providing hand over hand assist to help
him complete the task. Although fine motor tasks required extra time and frequent VP to facilitate task
completion and following directions, he did appear to enjoy playing in the Halloween sensory bin. Although
he did show some hesitancy when presented with the task and has shown some reluctance to engage in
messy tactile play during previous sessions, he was able to engage with this activity for a prolonged
amount of time. He even requested to continue exploring and playing with the items in the sensory bin
during his sensory break after the shape tracing activity (which he tolerated), but appeared more restless
than prior sessions. This week seemed more challenging due to a 3-week hiatus of not working with Client
directly, but not from reduced fine motor capabilities on the client’s part.

(P) Plan
Client will continue to be seen 1X weekly for 50 min to address fine motor control, visual processing, and
attention to increase his participation in school and home settings. For the next session, Client’s mom was
instructed to bring a “therapy outfit”, so we can continue to grade up his dressing goals and practice
dressing and undressing with his own clothing items to simulate a realistic dressing routine. Strategies that
will continue include: verbal prompting, physical cues, sensory breaks, visual schedule, and chair
modifications as needed.

Home Program: Shape tracing and counting worksheet.

Family/Care Giver Education: - Verbal - Written - Demonstration
-Homework Sent
Family/Care Giver Understanding of Education: -Verbal -Demonstration
 Occupational Therapy
Progress/Treament Note

x Continue Dischar Other: Next Appointment: 11/10/17

ge
Student Therapist Signature: Alexa Holguin

Supervising Therapist Signature: