You are on page 1of 9

OCCUPATIONAL THERAPY

PROGRESS/TREATMENT NOTE

Clients Name: O
Date: 12/03/15

Visit #: 8

Supervising Therapist: Heidi Woolley, OTD,


OTR/L
Student Therapist: Colton Savage, OTS
# Units: 4

Clients Goals:
1 Within 4 months, O will improve fine motor coordination and precision skills to cut out simple shapes

(3 diameter circle and 4 sized square) staying within of the line with 80% accuracy on 4/5 trials.

2 Within 4 months, O will improve fine motor precision and eye/hand coordination skills hold a writing

utensil with a tripod grip and write his first name and numbers 1-10 (letters and numbers being 1 in
size) with correct line adherence, number/letter formation , size and spacing with 80% accuracy on 4/5
trials.
3 Within 4 months, O will improve fine motor precision and eye/hand coordination skills hold a writing
utensil with a tripod grip and write upper case ABCs (letters 1 in size) with correct line adherence,
letter formation , size and spacing with 80% accuracy on 4/5 trials.
4 Within 4 months, O improve manual dexterity and bilateral hand coordination to button/unbutton 4/4
buttons on an item he is wearing (buttons being -1/2 in size) in under 90 seconds on 4/5 trials.
5 Within 4 months, O will perform fine motor & writing academic activities at school with good accuracy
in the allotted time frame with good compliance and without frustration or temper outbursts as
observed/reported by classroom teacher.
Clients Occupations to be treated include: (check all that apply)
ADLs/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)
Motor/Muscle/Movement
Sensory Skills
Social Skills
Skills
Temperatur
x Pressure
x Core
x Manipulation
x Engages/Approaches Others
x
x
x

Stability
Endurance
Position/Alig
ns
Joint Mobility

x
x
x

Coordination
Motor
Planning
Reaching/gr
asp

e
Hearing
Vestibular

x Tactile

Taste
Smell

x Concludes/Transitions/Takes turns
x Communicates (verbal/non-verbal)

Pain

x Looks/Turns (Makes eye-contact)

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

x Joint Stability
x Tone &

Strength

Reflexes

x Controlled

Movement

Other

x Propriocepti
ve
x Discriminati
on

Visual
x Modulati
on

Other

x Emotional Expression
x Physical behavior (regulates
movement, position, touch)
Other

Processing/Cognitive/Mental functions:

Visual Perceptual/Visual Motor Skills

Attends

Oculomotor Skills

x Object Perception

Memory

Visual Attention

Sequences Tasks
Executive Functions

x
x

x
x

Visual Discrimination
Visual Motor Speed

x Eye-hand
Coordination
x Copying Shapes
x Spatial Relations

Chooses/Uses
materials
Locates/Gathers
materials
Adjusts/Accommodate
s
Initiates/Continues/Ter
minates
Tasks/Activities
Other

Experience of self &


time
Emotional
regulation
Energy & drive
Notices/responds to
cues
Pacing of activities

Visual Memory

x Form Constancy

Organizes Materials

Depth Perception

Navigates
Environment
Orientation to self,
other, time & place

x
x

Visual Closure
x

Figure Ground

Visual Acuity
x Sequential Memory
Visual Closure

Other

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

Session Data
Subjective Data (Home Progress/Comments):
O and mother arrived for OT today. O seemed a little reticent at first, but warmed up as we
discussed the activities planned for the day. A visual schedule was used to introduce him to
the plans for the session. O demonstrated overall good attention to the activities today, even
when one activity was combined with another student. He was able to focus and finish the
activity. O enjoyed the Star Wars theme of the activities and seems more willing to
participate when theme is used. Caution should be used though due to the need to refocus his
attention a few times due to his desire to discuss Star Wars.

Accompanied by: Mother, Mother accompanied us to the area that the activities were
taking place.
Affect: Excited
Health Status: Well
Objective Data (ratio: #correct/ # trials and % accuracy, count: # of occurrences in a time frame, # min on task, etc.)
Progres
s
Assist
Prompt

M: Mastered (>80%)
GP: Good Progress (60-79%)
NA: Not Addressed
I: Independent

MinA:75%

ModA:50%

MaxA:25%

P: Progress (40-59%)

E: Emerging (<40%)

Dep: Dependent - 0%

S= spontaneous (w/o request) I= Independent (w/request, no other prompt) VP= Verbal Prompt M= Model (imitation)
R=refused/unable

Intervention Description

Objective Performance Data

Warm up: (5 Minutes)


Sensory Motor Activity:
Swung on platform swing using Halloween vampire
teeth (Wookie teeth) to pop bubbles that are blown
toward him focusing on vestibular and
proprioceptive input to improve organization skills
and focus on session.

Activity 1: (15 Minutes)


FM Handwriting
O used tracing sheets to trace numbers 1-10 as
well as the names on the star wars themed
worksheet. This was done to improve his bilateral
hand coordination while holding the paper, his
manual dexterity, fine motor precision, and
hand/eye coordination while writing,

O required 4 physical prompts while forming


the number 1 to use proper directionality
through his fine motor precision, and
hand/eye coordination.
O required 4-5 VP on using correct
directionality when drawing his magic c letter
o.
O requires 1-2 VP in his bilateral hand
coordination of holding the paper while
writing.
O required 3 VP and Modeling of proper
formation of letter 8.

O was able to independently swing while


sitting and popping bubbles.
Fine motor control was used while moving
Wookie teeth to prepare him for writing
activities next.

Activity 2: (15 Minutes)


O required 4-5 VP during activity to return
GM/ Sensory/Letter formation activity/ Social
focus to activity.
Created letters of Os name on floor using masking
O required 4-5 VP in remember the proper
tape. Therapist assisted in placing letters on floor.
formation of the letters e, and v
Also 5 other letters were formed on floor, all letters
O was Independent in his bilateral
scattered across room. Another client joined us and
coordination of placing the tape on the floor.
he also taped down the letters of his name. Each
O also required 4-5 VP in following directions
child took one turn directing the other on what
as the other child told him which letters to
letter they need to jump to get to the
jump on.
predetermined destination at the end of the letters.
This was used to improve his letter formation, and
Division of Occupational Therapys LIFE SKILLS CLINIC
540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

bilateral coordination

Activity 3: (15 Minutes)


FM/cutting
Began a cutting activity. O was required to first plan
out the different shapes that would be required for
the entire project off of an image provided. He then
drew a rectangle, and a circle in preparation for
cutting. At this point time was over for activity.

O required 3-4 VP to return attention back to


making the list for the items needed.
O required modeling and modA in drawing his
rectangle, but was independent in drawing
the circle.

Cool Down: (5 minutes)


Sensory/Organizing
Cool down consisted of yoga poses disguised with
star wars terms. Airplane (x-wing fighter) was used.
He then was asked to remember one pose from a
previous day.

O required modeling to perform the poses.

This activity is used to give large amounts of


proprioceptive input designed to reorganize the
system and prepare to transition from clinic to
home.
Home Program: No homework was given at the end of the session, but there was a discussion during
session of possibly meeting during the week of 12/13-12/19, which I am up for.
Family/Care Giver Education:
X - Verbal
-Written
X- Demonstration
Homework Sent
Family/Care Giver Understanding of Education:
X -Verbal
-Demonstration
Assessment: (Analysis of data Does data show progress, maintenance or decline? What contributed/interfered
w/performance? Effectiveness of cues, grading of activities, assist, etc. How did affect, focus, health, etc. impact performance?
What does todays performance suggest for next session? What was discussed w/parents?) O is continuing to make

progress in the legibility of the alphabet. His legibility is still around 60-65%. After missing a week of
interventions (due to Thanksgiving) he regressed on his proper letter formation, going back to forming his
magic c letters using a clockwise formation rather then counterclockwise. O required less prompts to
refocus attention on tasks, and had less times that he lost focus on the task at hand. According to what
happened this session, next session we will refocus on proper formation of race car letters, on bilateral and
hand/eye coordination.
Plan:

(What will you focus on next session? Changes in cueing, adaptations, assistance, etc. What strategies to continue?
New strategies Discontinue strategies? Probe other behaviors/responses? Other testing needed? Contact family, other
professional, school?)

Next session we will focus on correct letter formation of race car letters using a counterclockwise
formation. We will also reintroduce the fireman letters. Hand/eye coordination, bilateral coordination, and
fine motor control will be the focus during these written activities as well as cutting and pasting activities.
A list of gross motor activities that mom can do at home with O to promote the proper formation of the
race car letters will be give to her as homework. I will encourage her to do at least a couple of the items on
the list before the next session.

x Continue

Dischar
Other:
ge
Student Therapist Signature:
Supervising Therapist Signature:

Next Appointment 12/10/2015

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

Community Client SOAP Note Grading Rubric


OCTH 6140 Pediatric Interventions & Skills

Name:

Colton Savage

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

Session/SOAP Note #:
8

Session Date:

SOAP note is a note about what actually happened in a session. Should be written in past tense.
Should state the childs name (not initial or student) Its for insurance to review when they audit
they need to have documentation to justify them paying for the service and also need to review
for progress so they will authorize continued visits. It needs to document skilled intervention,
measurable/observable relevant data (both subjective and objective), document & assess
progress towards goals, and then plans for continued sessions.

SOAP Note Grading Criteria

Criteria

Examples

1. Demographic information: precautions, therapists


name, Student Name, Date, Visit #, tx Units and goals
identified

2. Session occupations: correctly Identified for this


session

3. Session Skills:, Client Factors, Performance Skills &


Performance patterns correctly Identified for this session

4. Subjective Session
Data Complete: Always
need to have a t least a
Brief narrative about what
happened at home, progress,
concerns, homework
feedback, also what

Skill Level Demonstrated


Below
Expectatio
ns
0-.5 Pts.

Meets
Expectatio
ns
.75 Pts

Outstandi
ng
1 pt.

x
x
x

Cooper arrived for OT today


excited and ready to participate
in therapy. He was introduced to
the session with a visual
schedule. Cooper demonstrated
good attention to the activities
and directions. He was able to
transition between activities and

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

happened in the session, etc.


This part is any pertinent data
related to progress or working
on goals that isnt put into
bulleted short measurable
data points. )

rooms with minimal distraction


between activities through
minimal verbal cueing. Dad
expressed that Cooper has been
having a lot of trouble
transitioning between nonpreferred activities and is
displeased in his current school
situation (e.g., lack of
accommodations). They are
thinking about moving Cooper to
a new school.
Accompanied by: Dad
Affect: Energetic-happy and
ready to interact and engage in
the activities
Health Status: Good

5. Interventions

1. Fine Motor/Sensory activity:


On swing completing a
cut/paste/color activity.
Hugged swing to promote calming
modulation skills w/proprioception &
vestibular input.
Had client prone in the swing to
increase core & UB strength while
tracing horizontal lines & then cut
along the lines with non-adapted
scissors. emphasizing bilateral and
eye-hand coordination skills. Went
through x2
2. Gross Motor/Sensory Motor
Coordination: Completed obstacle
course incorporating movements to
build UE strength and give
proprioceptive input, with slow
rhythmic movements to promote self
regulation. Had client slide down
slide different ways to work ideation.
3. Completed shower routine
incorporating visual cues/check list
focusing on increased independence
decreasing verbal cues towards
gestural cues. Focus on verbal
positive reinforcement at end of
task. Focus on -Improve sequencing
of steps, attendance during tasks,
and fine motor skills to increase
independence in self-care activities.
1. Sensory: remained calm
throughout swing, willing to
participate in tracing/cutting.
FM: tripod grasp -100% Ind. Traced
6 in. with 50% accuracy w/in of
line. Required set-up and VP for
scissor use. 25% accuracy cutting
w/in of 6 in. line.
2. UE strength on scooter board

Description: accurately
described & analyzed - This
section justifies to
insurance why they are
going to pay for therapy.
What about the activity is
therapeutic and why they
would pay you to do this
versus if a parent, teacher or
caregiver were doing this with
the child. This doesnt have to
be long but it has to contain
a brief description of the
intervention with what skills
you are targeting towards
what functional outcome.
(HINT: Combine simplified
version of activity description
from treatment plan with
anticipated outcomes from
treatment plan)

6. Objective Data :

accurately documented - This


section should be Brief
bulleted phrases of
measurable data on targeted
skills you stated in
intervention description.

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

15 ft. only using arms x4 w/o tiring


or losing attention (GP from last
week only would do 5 ft., requiring
VP for attention/pacing)
Climbed slide x4, 100% accuracy
Remained in bean bag x4 w/o VP
FM/pincer grasp latch board 80% I,
VP x3 for sequencing/attention

3. -Doff clothing: S, I

-Put clothing on bench: 2 VP


-Turn on shower: S, I
-Wet hair: 3 VP, modeling x2
-Squeeze soap onto hand to
wash hair: 3-4 VP, ModA, hand
over hand
-Wash hair: 3-4 VP, modeling x3
-Rinse hair: 4-5 VP, countdown
from 10
-Stepped out of shower before
finished 3x; 1-2 VP per
occurrence to step back in
-Turned water to faucet (rather
than shower) 4x; 1-3 VP and
ModA per occurrence to stand
and turn shower back on, 2
countdown from 5
-Almost bit hand 1x, but stopped
w/ 0 VP

7. Home Program: accurately described/documented. You


should ALWAYS have homework for families to complete. This
section includes what you told them during the session to do
at home to reinforce the skills you are practicing in the
session. It should also include what written information you
gave them. Homework and follow through is always more
likely to happen if you give them something they have to mark
down, complete or bring back. It gives family accountability.
ALSO at least 1x a month you should include some kind of
educational materials to the family. A list of activities to do to
promote a skill, resources, development education, etc.

8. Family/Caregiver Education documented

9. Assessment: Accurate
analysis of data/observations
made during session
Professionally and concisely
written. DO NOT restate
objective data here. You
summarize what objective
data means and then state

Cooper made significant progress


from last week in his sensory
modulation/regulation and attention
span. He improved consistency w/
tripod grasp, but does required
modeling and verbal prompting for
pincer grasp. This is likely a
combination of attention span and
frustration. He is able to legibly write
all letters of his name except e and

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

how this is impacting goals


and functional skills.

r. Remains focused on writing the


letters until that point and then gives
up. Cooper made good progress (on
attending to table top activities
w/minimal verbal prompting, but the
addition of the seat wedge provided
him with additional input for activity
tolerance and attention. His father
reports dissatisfaction with Coopers
current school program. The family is
considering switching schools as
they are not seeing accommodations
and attention they were hoping for.
Discussed the importance of
proprioceptive input including the
use of a seat wedge or ball for
Coopers attention span during table
top activities. He reports that he will
bring this up to Coopers school.

10. Plan: concise statement


of what next session will focus
on - NOT restatement of
goals or Continue current
Plan This builds on
Assessment section what
skills are you going to focus
on in next session to promote
what skills?

Next session we will focus on fine


motor dexterity and accuracy to
promote letter formation, cutting,
and buttoning skills. Will continue to
work on handwriting goals through
gross motor and sensory motor
activities to facilitate continued
focus, body awareness, and
coordination to enhance strength
and activity endurance. Will also
continue to implement strategies to
ease transitioning from activity to
activity (specifically non-preferred
such as going home, handwriting,
etc.), as this is very important to
both parents. Will begin to practice
capital letter formation to improve
functional legibility and sizing.
Cooper responds well to repetition,
so we will test the HWT method of
Wet-Dry-Try with Frog Jump capitals
(E, D, P, B, R, N, M) over the course
of treatment. Will also begin to
implement functional sizing
strategies including sensory-based to
continue to help Cooper learn to
regulate and modulate input/output

11. Spelling/Grammar - Correct grammar, punctuation,


spelling, or organization Professionally written
12. On time submission - (DUE 2 business days after
session - so therapist can give feedback for next session tx
plan) -.5 points for every day late
Grading Rubric:
Students Final Grade:
Student meets expectations in all criterion categories
= 9/10 Pts.

x
Days Late

On Time
x

10.25

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu

OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE

Total Possible Points: 10.25/10

Comments:

Division of Occupational Therapys LIFE SKILLS CLINIC


540 Arapeen Drive Suite 200
Main Clinic Number 801-585-6837FAX 801-585-6813www.LifeSkillsClinic@utah.edu