Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN

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Occupational Profile & Intervention Plan
Danielle Palmer
Touro University Nevada

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Occupational Profile
Client
Emily Thompson, a 27-year-old woman, was diagnosed with a mild intellectual disability
and Type I Bipolar Disorder when she was 10 years old. Emily’s father passed away right after
she was born and her mother was unable to take care of Emily. Emily has no contact or
information about her mother. She grew up in Los Angeles, California in their foster care system.
Emily reports that she enjoyed living with her foster parents, but they were strict and did not
“understand her” sometimes. Emily attended Los Angeles schools, and is a high school graduate.
In 2005, at age 17, she was briefly hospitalized in a psychiatric setting due to an outburst with
her foster family. When Emily was 22, her sister, Amanda, took responsibility for Emily and
moved her to Las Vegas. Emily is very close to her sister and does not have any other siblings.
Amanda is stable, reliable and takes good care of Emily. She works a full time job while Emily
attends Easter Seals. Emily is now close to her grandparents, who also live in Las Vegas. Emily
has been attending Easter Seals for three years. She rides the transit system to and from Easter
Seals every day. She is in the process of transferring over into the Opportunity Village’s
vocational training within the next 6 months. Emily is very excited to start at Opportunity Village
because she eventually wants to get a paid job to become more independent in order to live on
her own.
Current Concerns
Emily wants to become more independent in her life. She does not want to keep living
with her sister and attending Easter Seals. She wants a paid job and a place of her own. Amanda,
Emily’s sister, is concerned that she is not ready for independent living because she lacks certain
basic life and safety awareness skills. Amanda believes that it would be unsafe for Emily to live
on her own and it would be a constant worry. Amanda supports Emily in her pursuit of a job and
believes she can be successful. Amanda knows that Emily would gain more self-confidence with

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employment. Emily is motivated to be engaged in therapy and learn the skills needed for her to
become more independent. She wants to complete her therapy in the community setting.
Occupations
Emily is independent in all of her basic activities of daily living. She completes all of her
personal hygiene and grooming tasks independently. Emily enjoys taking care of her dog, Sam.
The dog is Emily’s responsibility and she has to feed him twice a day. Sam even sleeps with her
at night. Emily loves to text her friends back in California. She also loves to draw and keeps a
notebook with her at all times, where she can doodle and sketch anything that comes to mind.
Emily prides herself in the work she completes at Easter Seals. She can make simple meals and
carry on basic conversations with her peers.
Amanda does not allow Emily to use the stove because she does not fully understand the
concept that the stovetop is hot and will burn her. Emily also does not know how to use the
controls on the stove. Emily understands how to operate a microwave and is allowed to use the
microwave but only with supervision from Amanda or a staff member at Easter Seals. Amanda
selects all the groceries for their household. She takes Emily to the grocery store, but Emily is
not involved in the meal planning process. Amanda is in charge of the money and the food
budget. Emily does not understand the concept of a budget.
Environment
Emily lives at home with her sister. She states that she is allowed to be home alone but
only for a couple of hours at a time. If her sister is gone for any length of time, she stays with her
grandparents. She lives in a one-story home. Emily has her own room, which is decorated in
Seattle Seahawks colors, her favorite football team. She visits her grandparents every weekend
and usually spends at least one night with them. Emily and her sister go to the movies and out to
dinner approximately twice a month. Emily states that she does not like her neighborhood
because most of her neighbors are old. She has friends in California but has not made many close
friends in Las Vegas. Emily lives in a very supportive environment that fosters her ability to

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grow. Her sister and her grandparents are a constant in her life and want her to succeed. Amanda
gives Emily some freedom, but keeps a close eye on her. Her environment is safe but Emily feels
that she is sometimes too confined. Her grandparents and sister always want to know where she
is and what she is doing at all times. She wants more freedom to explore and become more
independent.
Occupational History
Growing up, Emily’s main occupation was school. She enjoyed school, especially art and
music. Emily made many friends in her school in California. She loved watching movies with
them and listening to music. Her foster parents were very religious and would go to church every
Sunday. Emily would go but she stated that she often got bored. When she moved to Las Vegas
with her sister, her main occupation became her work at Easter Seals. Her work involves
completing various activities that relate to real life skills. Her tasks include: shredding paper,
making copies, reading, tying shoes, telling time, sorting and folding clothes, counting and
sorting money, and playing games. In the future, Emily wants to apply these real life skills to
help her find a job through the Opportunity Village’s vocational program. For fun, Emily has
always enjoyed swimming, texting her friends and drawing.
Values and Interests
Emily loves to spend time with her sister. She also likes visiting her grandparents and
swimming in their pool. Emily enjoys watching sports and discussing the game and the current
players with her friends and family. Every week during football season, she watches the Seattle
Seahawks, her favorite football team. She also likes to listen to music and is very interested in
art. Her favorite activity at Easter Seals is the community outings. Easter Seals has taken her to
many different places, such as the local library, park and bowling alley. Her favorite outing was
a trip to Red Rocks because she loves to be outdoors. Emily has a smartphone and is adept at

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texting her friends in California daily. She has had a difficult time making friends in Las Vegas.
She says she has one friend at Easter Seals in a totally different classroom.
Daily Life Roles
Emily is responsible for preparing her lunch that she brings to Easter Seals. She packs
food that does not have to be cooked or that can be heated in the microwave. She also packs
extra food for snack time. Emily is responsible for taking care of her dog, Sam, which includes
feeding him twice a day and ensuring that he is brushed and exercised. Emily also has to keep
her room clean on a daily basis, and helps vacuum the house on cleaning days. Having this role
of helping out in the house is important because it makes Emily feel like she is included and also
making a contribution. Emily’s role as a sister is very important to her. She loves her sister and
wants to spend more time with her. Amanda is Emily’s main support system and she treasures
that relationship. If Emily ever has any issues, she trusts her sister to help her. Emily also values
her role as a granddaughter and loves being with her grandparents. Emily’s role at Easter Seals is
important to her. She is proud of what she has accomplished and the work she does. It gives her a
sense of wellbeing and responsibility.
Patterns of Engagement in Occupations
Emily’s main occupation in California was going to school. Her foster parents completed
all of her cooking, laundry, and basic household chores. Since moving to Las Vegas, Emily has
become involved with many more occupations and has taken on added roles and responsibilities.
She has gained more confidence in her abilities and pushes herself to continue to expand her
range of occupations. She performs basic cooking, cleaning, and taking care of her dog. Her
abilities have increased overtime. There are still occupations that Emily cannot complete without
supervision because of safety issues and complex cognitive abilities, but she is willing to learn to
the best of her abilities.
Priorities and desired Targeted Outcomes

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The client’s overall goal is to become more independent. Emily wants to find a job in
order to live on her own. She wants to improve her occupational performance in the areas she is
struggling in so she can achieve her goals. The client also wants to increase her quality of life by
expanding her range of occupations. Emily wants to be safe in all of her occupations and
maintain her health so she can live on her own and her sister does not need to worry about her.
By becoming employed and living on her own, Emily will expand her roles in life and improve
her overall wellbeing.
Occupational Analysis
Context/setting of Occupational Therapy Services
Emily receives services at Easter Seals Nevada. She participates in the Adult Day
Services, where she is working on various skills to increase her independence. Emily is currently
assigned to a room with other high functioning adults with primarily cognitive disabilities. Emily
and her peers sit at large tables to complete their activities. The room also contains a full kitchen
and bathroom. The kitchen has a microwave, stove, and all needed supplies. The cabinets are
full of food for the clients. Cold water, and packed lunches, and other additional foods are
located in the refrigerator. Therapy sessions can take place in this room or clients can go with
their therapists to different community settings. This allows clients to complete therapy in real
life situations, which is invaluable to the clients.
Activity and Client’s Performance
I observed the client preparing soup for lunch at Easter Seals. She went to the refrigerator
to retrieve her lunch bag, which contained Top-Ramon noodles. Emily stated that she has
noodles for lunch almost every day. She went to one of the staff members to ask where she could

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find a bowl. She was told her that they were where they had always been in the last cupboard on
the right. Emily nodded and grabbed a bowl from the cupboard. She then poured the noodles into
the bowl and went to the sink to put water in the bowl. Then she carefully picked up the full bowl
and put it into the microwave. She started to open the container to add the seasoning packet when
the staff member stopped and reminded her to add the seasoning after the noodles were cooked.
Emily complied and then went to microwave and set it for two minutes. Once the timer went off,
she immediately went to grab the bowl from the microwave. She seemed unconcerned that the
noodle mixture was extremely hot. A staff member quickly ran over and reminded her that it
could be hot. She nodded and carefully lifted the bowl and walked over to where she was sitting.
Then she poured the packet of seasoning into her soup. She then told me she had to wait while it
cooled off. After a 5-minute wait, she proceeded to eat her soup.
I also observed Emily completing a money activity. She was completing a worksheet
about counting money. The worksheet had different scenarios for Emily to complete; for
example, the worksheet showed a picture of a quarter, a dollar, and a penny and she needed to
supply the sum of the monies. Emily took her time and used a scratch piece of paper to write out
the amount of each piece of money and then add them up. Emily answered every question
correctly; she just needed some extra time. The next section asked her if she could buy a $10.00
backpack with a five-dollar bill and four one dollar bills. She was completely confused and did
not understand how to complete the question. The staff member tried to explain the question to
her but she did not understand the concept.
Key Observations

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There were many key observations that I saw from these two activities. With the cooking
activity, I noticed that Emily had some difficulty sequencing. First, she could not remember
where the bowls were located in the kitchen; it was implied from a staff member that she should
know where they were. Then, she wanted to put the seasoning in the soup before she cooked the
noodles. This would not be alarming if this were a novel task for the client. But Emily stated that
she makes noodles all the time for lunch. Another key observation was that the client was
unaware of how hot the soup had become and that it could potentially burn her. When she was
reminded of the heat factor, she then took extra caution with the soup. But, it is important to note
that she has to be reminded continuously of this safety issue. With the next activity, a key
observation was that Emily was very good at counting money; she just needed some extra time to
figure out the worksheet problems. But, she always came to the correct answer. She was
completely unaware of how to budget money, which is a key skill Emily needs to learn if she
gets a job and plans to live more independently.
Domains of the OTPF
Many of the domains in the Occupational Therapy Practice Framework have been
impacted because of the client’s diagnosis (American Occupational Therapy Association
[AOTA], 2014). Emily’s process skills have been affected. She has difficulty locating and
gathering the supplies and the tools needed for cooking. She also has a difficult time sequencing
and timing the steps involved with cooking. She completes tasks out of order. Another domain
that has been affected is high-level cognition. Emily does not understand that food heated in a
microwave can be very hot and dangerous. But, when given a reminder, she acts accordingly to
ensure she is cooking safely. Safety is a huge issue that needs to be addressed immediately.
Emily also does not have the high-level cognition to understand how to budget her money as

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well as what money is needed to buy specific items. This is a crucial domain that needs to be
addressed if she is going to complete her own grocery shopping. She can count money, when
given time, but has not been able to apply that information to a budget. Her personal
environment is also affecting the ability to successfully engage in her occupations. Her sister is
very protective of Emily, and has not facilitated any learning of cooking with the stove or taking
part with the grocery shopping. Amanda needs to let Emily experience more occupations so she
can learn and grow more independent, (AOTA, 2014).
Problem List
1.) Client requires SPV when cooking on a stovetop 2° sequencing & safety concerns.
2.) Client is unable to understand the value of money & the concept of a budget which limits her
ability to make (I) purchases in the community.
3.) Client requires 3x amount of normal time when counting money 2° cognitive attention
deficits.
4.) Client requires 1 VC when tying her shoes 2° sequencing difficulty.
5.) Client requires 3x amount of normal time when telling time on a clock 2° cognitive attention
deficits.

Justification
The client emphasized that her main goals are to find a job and live independently. If
Emily ever wanted to live by herself, safety is the main concern that needs to be dealt with first.
All of the other problems are important but safety is the priority. That is why the first problem
statement addresses safety in the kitchen. The client wants to live by herself and the safe use of
the stove to cook food is essential. The client’s understanding of a budget, the second problem
statement, is also important for independent living. This is a major issue, because the client needs

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to understand the concept of a budget in order to successfully purchase food and other necessary
items without going into debt. The rest of the problem statements are extremely important but
the client is able to count money and tell time when extra time is provided. The one verbal cue
needed to tie her shoes is important but with repetitive practice, the client should be able to
complete the skill with no verbal cues. The client should work on this, but it is not a crucial
concern. Learning to cook safely in the kitchen and budgeting money is more important.
Intervention Plan & Outcomes
1.) Functional Problem Statement: Client requires SPV when cooking on a stovetop 2°
sequencing & safety concerns.
LTG: Client will cook boxed macaroni & cheese, on the stovetop č Mod (I) within 4 months.
STG 1: Client will gather supplies to cook boxed macaroni & cheese & state the step by step
instructions to OT č SPV within 2 months.
Intervention: On the first day of therapy, Emily will complete the Rabideau Kitchen Evaluation.
This assessment evaluates a client’s ability to sequence a functional task by using a simple
cooking task. The assessment takes 10-15 minutes and the client is asked to prepare a hot
beverage and a sandwich. Each of the tasks is broken down into simple steps. The client is
evaluated on how well they complete the steps needed for the particular task. Emily would only
use the hot beverage portion of the assessment because it involves the hot stovetop. This is a
good pre and post assessment to compare Emily’s progress throughout the intervention process.
This assessment will take place in the kitchen at Easter Seals. Following the assessment, Emily
will first find the list of supplies on the back of the macaroni and cheese box. She will have to
locate the supplies in the kitchen that are needed to make the macaroni and cheese. The supplies

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needed are: a pot, measuring cup, spoon, milk, butter, and the package of macaroni and cheese.
Emily will have to gather all the supplies needed. These supplies can be found in the kitchen
cabinets and the refrigerator. The therapist will provide verbal cues and supervision for Emily.
The therapist will also make signs to attach to the cabinets to show where the materials are
located. If Emily is unable to find the materials, the therapist will assist. The client will also have
to locate the directions on the back of the box and read the directions out loud to the therapist.
The therapist will provide cueing if the client become confused with the sequencing instructions.
This intervention will have to be repeated multiple times throughout the treatment sessions for
the client to fully grasp the task.
Approach: This intervention uses the establish approach (AOTA, 2014). The client is
establishing a skill that has not yet been developed. The client has never cooked a complex meal.
The client has to learn how to find and gather the appropriate supplies and then find and read the
instructions on the box. These are vital skills the client needs to learn in order to be able to cook.
Research: According to Willard and Spackman (2014), external cues can be beneficial by
helping the client become oriented to the environment which, in turn, helps the person feel less
confused. Pictures showing where objects belong, arrows for directions to a room, or a calendar
are external cues that can be used. These adaptations can be used directly in therapy with the
client or as part of caregiver training. Do not put too much information on a poster or sign
because this can become too confusing to the client.
Outcome: This intervention improves the client’s occupational performance (AOTA, 2014). The
client is learning the skills needed to cook a complex meal on the stovetop. The client wants to

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be able to cook on the stovetop as a part of living independently. This intervention gives the
client the foundational skills needed when cooking a meal on a stovetop.
STG 2: Client will demonstrate how to operate the stove & explain the safety concerns of
cooking on a stovetop to OT, č SPV within 2 months.
Intervention: The client will complete the intervention in the kitchen area at Easter Seals. The
therapist will show the client how to operate the stove and provide a demonstration of how to
turn the stovetop on and off, how to make the temperature cooler or warmer, and the safety
issues with the stovetop. The client will then be able to explore the different components of the
stove and try out the different settings as it relates to cooking. The client will practice with a pot
of water. The client will put the pot of water on the stove, turn on the stove, and adjust the
temperature until the water is boiling. The client will then turn off the stove, and transfer the pot
of water onto a part of the stove that is not hot. Throughout this process, the client will use safety
precautions and verbally explain to the therapist the safety concerns when cooking on a stovetop.
The therapist will be supervising and cueing Emily throughout the process. This intervention will
be repetitive in nature until it becomes a habit for the client.
Approach: The approach used for this intervention is establish (AOTA, 2014). The client has
never been allowed to use the stove because of safety concerns. The client has now established
the skills to understand how to operate the stove and the safety concerns related to cooking on
the stovetop.
Research: According to Willard and Spackman (2014), verbal mediation is an effective strategy
for improving occupational function. For this type of intervention, the therapist requires the

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client to verbalize what they are doing before and during the occupation. This progresses from
talking out loud to whispering to themselves. It can be generalized to real-life situations.
Outcome: The intervention outcome is to increase the role competence of the client (AOTA,
2014). Through the intervention, the client will have learned the demands of the role of cooking
a meal on a stovetop. The client will learn to operate a stove and understand the safety concerns
involved, which are skills needed for a person who wants to live independently. This will
enhance the client’s overall self-efficacy and meets the demands of the role of being a
homeowner.
2.) Functional Problem Statement: Client is unable to understand the value of money & the
concept of a budget which limits her ability to make (I) purchases in the community.
LTG: Client will purchase groceries for dinner for under $10.00 Mod (I) within 4 months.
STG 1: Client will locate 5 items, all under $2.00 at the grocery store č SPV within 2 months.
Intervention: The client will explore the grocery store with the therapist to locate five items,
each under $2.00. The client will orientate herself to the grocery store. Emily will discover what
areas to find particular food; for example, where the produce section is located in relation to the
freezer section. The client will shop in one section of the store at a time to make her selections,
so she will not be overwhelmed by too many choices. The client will find these items and tell the
therapist the exact price of the item. The therapist will correct the client if she is wrong and guide
her throughout the process. This intervention will also be repetitive in nature. The client will
need a great amount of practice orientating and finding items under a specific amount. There are
many options in the grocery store so this intervention can be performed many times without
repeating items.

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Approach: The approach needed for this intervention is establish (AOTA, 2014). The client did
not have the skills needed to budget her money and buy items under a strict amount of money.
These are skills that had to be established in order for the client to shop independently. If the
client cannot budget her money, then she will not be able to live independently.
Research: According to Willard and Spackman (2014), completing occupations in large, busy
environments can cause issues with attention. Breaking down the task and only completing one
component of the task at a time can be beneficial. The client will not get overwhelmed and can
focus on one small segment of the entire task.
Outcome: This outcome would be improvement of occupational performance (AOTA, 2014).
The client now has the basic skills to find items under a certain amount of money, which is a
crucial skill needed when budgeting money. This is needed if the client is going to live on her
own and buy her own groceries. This outcome increases her independence and makes her a more
competent shopper.
STG 2: Client will use the grocery store flyer to determine which items she could purchase for
under $15.00 č SPV within 2 months.
Intervention: The client will use a department store flyer and explore how the flyer is set up in
different sections: women clothing, men’s clothing, electronics, home goods etc. Then, the client
will search the flyer to determine what clothing items she could purchase for under $20.00. The
client will pick out the item or items that she could purchase for under $20.00 and add up the
price or prices to find the exact total. The total needs to be under $20.00. This intervention has to
be repetitive in nature and can use different department store flyers from each week to make it a
little different. Emily will practice finding different pieces of clothing that she could buy under a

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set budget. This intervention is occupation-as-a-means and is related to the client’s goal of
becoming more independent. As of now, Emily’s sister takes Emily shopping for clothes. Emily
picks out the clothes, paying no attention to the price, and Amanda pays for them. This skill of
using a department flyer to find items under a budget can also be used to find items in a grocery
store flyer and budget items for groceries.
Approach: The approach for this intervention is establish (AOTA, 2014). The client had to
establish the skill of using a department store flyer and become competent in budgeting her
money for under $20.00. The client had never used a department store flyer before. The client
had to establish the skills needed to navigate the flyer and find items she would like to purchase.
Research: The study analyzed how cognitive deficits can impact IADL functions, especially in
people with depression. Money management was an impaired IADL for clients with a cognitive
deficit. Budgeting money requires planning, organization, and initiative, which can be difficult
for this population. The study goes into detail about how planning out a strict budget and
assigning specific times to pay bills can be very beneficial to the client, (Kiosses & Alexopoulos,
2005).
Outcome: The outcome for this intervention will be increase role competence by meeting the
demands of an independent woman (AOTA, 2014). The skills established in the intervention
improve the client’s ability to plan, budget, and decide what clothing the client should buy. These
skills are vital for a person who wants to budget money in order to live independently.
Precautions and/or Contraindications
The client needs to take extreme precaution with safety when cooking on the stove.
Through the interventions, the client should understand how to operate the stove as well as the

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crucial safety precautions needed. These are vital skills needed for cooking. The client
understands that, if there is any issues or fires with the stove or feels unsafe, that she should
immediately call 911. The client should have the 911 number posted next to the stove so she
knows exactly who to call if there is an emergency in the kitchen. The client should leave the
situation and wait outside until the emergency response team comes. The client should also be
aware of the consequences if she is on a budget and does not have enough money. She cannot
buy the items and needs to be more successful at budgeting for the next month. The client should
plan out every meal and budget before she goes to the grocery store. If the client has not made a
list before she goes to the grocery store, then it is easy to pick out random items and over spend.
The client should be aware that the grocery store could be very busy at certain times of
the week. The grocery store is usually busier on the weekends and after 5 pm on the weekdays
because people are just getting off work. The client should avoid shopping at these times because
grocery shopping can be an overwhelming experience and adding crowds of people can be even
more overwhelming. The client cannot drive, so she should consider this when shopping for her
groceries. If she is taking a bus, she can only buy groceries that can be carried. If she goes
grocery shopping with her sister, who has a car, then she can buy more groceries. But she should
always be aware of the budget.
Frequency and Duration of Intervention Plan
The client will be seen 3x a week for 1 ½ hours each session for 4 months. Easter Seals
only operates Monday- Friday so the client will be seen sometime in this timeframe. This intense
therapy will push the client both mentally and physically. The therapy will be conducted in the
kitchen at Easter Seals, and in the community’s grocery store. Emily will be seen one on one

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with an occupational therapist at approximately 10:00 am, after the client has had her snack. The
client will not be seeing any other therapist at this time. Throughout Emily’s treatment at Easter
Seals, her progress will be tracked through written documentation. At the end of the 4 months,
Emily will be reassessed to monitor his progress and determine the next step.
Grading up and Grading down
Intervention: The client will use a department store flyer and look through to find what clothing
items she could purchase for under $20.00. The client will pick out the item or items that she
could purchase for under $20.00 and add up the price(s) to find the exact total. The total needs to
be under $20.00. Grade up: The client will locate coupons in the department store flyer and
determine how to apply these coupons to her clothing items. Grade down: The client will use
the department store flyer and find one item for under $10.00.
Primary Framework
The dynamic interaction model, which is a model of cognition, was the primary
framework used for this intervention plan. This model looks at the interaction of the person,
activity, and the environment. It is used to teach specific cognitive strategies in order to improve
task and occupational performance. The client practices the task repetitively in different activities
and settings. Overall, this model can be compensatory or remedial. This model guided this
intervention by assessing Emily, what occupational deficits she was experiencing, and the type of
environment she was in. By using this information, intervention planning and goals were created.
The intervention plan contained repetitive activities that were suited to the client and were
completed in different environments. The environments where the interventions took place were
where the occupations would actually take place, ex: a kitchen and a grocery store. Through the
use of repetitive activities, and compensatory strategies, the client will be able to reach her goal.
Client/Caregiver Training and Education

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The client will be provided training and education throughout the treatment process. The
client will be trained on how to operate a stove, along with the essential safety precautions.
Emily will also be trained on making purchases within a budget. The client can ask questions
through the treatment process and tell the therapist what she wants to get out of the whole
therapy process. Education for Emily’s sister, Amanda, will also be crucial. Amanda is the
primary caregiver for Emily at this time. Amanda works fulltime, Monday through Friday. The
occupational therapist will set up a time each week to call and talk to Amanda about Emily’s
progress in therapy and issue that might have come up. Working with Amanda will be vital for
this intervention plan to be effective. Amanda and the occupational therapist will have to
collaborate to get the most out of Emily’s therapy. The occupational therapist will work on the
skills during the therapy session, but Amanda will have to continue practicing those skills with
Emily at home. Cooking on the stove and budgeting are two skills that will be addressed in
therapy but will be vital to address at home also. Through practice, repetition, and guidance from
both the therapist and Amanda, Emily will make progress and reach her goals. Emily’s
grandparents should also be educated on Emily’s therapy in order to help foster her growth in
these skills.
Response to the Interventions
The client was assessed using the Rabideau Kitchen Evaluation on the first day she
started occupational therapy. The Rabideau Kitchen Evaluation will also be given to the client at
the end of the 4 months of treatment. Emily will be assessed during each treatment session and
documentation will be recorded on how well she did during her treatment sessions dealing with
her specific goals. The documentation, at this time, is completed in a paper format. Easter Seals
is trying to convert all documentation to digital and online format. The online format would
make it easier for all staff members and therapists at Easter Seals read and determine how Emily

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is doing in therapy. Right now, each client has an assigned binder that contains all of the
information. This information includes: medical documentation, client’s diagnoses, goals,
treatment documentation, and services they are receiving. These are all vital documents that
allow the staff members and therapists to track the client’s overall progress.
After each treatment, the therapist documents everything that happened within the
treatment session, in a paper format, and puts it into the client’s book. The documentation
includes Emily’s long term and short term goals that are being addressed in the sessions. This
allows the therapist to document what the client accomplished during the session, if the client
met and completed any of the short term or long term goals, and if any other considerations were
addressed. The documentation also contains information on any changes that were made; for
example, if the goals were too hard or too easy for the client to complete.

References
American Occupational Therapy Association. (2014). Occupational therapy practice framework:
Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl.1),
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