S: Mother states that she has no major concerns that are not being addressed in therapy.

O: Client is a 10-month-old (7 months adjusted) female seen for extreme prematurity, feeding
difficulties, chronic lung disease, and retinopathy of prematurity (ROP). Client was seen in her
home with her two triplet sisters. When placed in a hip and knee flexion position, client rocked
back and forth for three sets with maximum assistance, and when placed in a quadruped
position rocked two times with maximum assistance. She maintained a static quadruped
position and transitioned from quadruped to sitting with maximum assistance. She did not
reach for presented toys in quadruped. Client pulled herself up on a cube toy with moderate
assistance and played in low kneeling with minimum assistance for three minutes. She spun
pieces on cube, rotated toy, and banged on toy with hands. Client transitioned from sitting to
pulling upper body onto boppy pillow with maximum assistance and remained in low kneeling
for two minutes with SBA. She demonstrated pivoting on stomach to L and R to turn toward
toys. She is independent in sitting, demonstrating mostly ring sitting today. She stood with
moderate assistance at upper trunk for two minutes, and stood with hands held for one
minute. Client independently reached for toys presented to her and on her own in sitting with
bilateral UE, and independently held two toys simultaneously. She reached for a presented toy
while holding a toy in one hand, smiled and waved her arms, and banged toys together on one
occasion. On one occasion she picked up one toy from ground, then another, smiled and waved
her arms, and banged toys together two times. During a bottle feed, she independently reached
toward the bottle to hold for herself, and demonstrated self-feeding for four minutes. After
feeding, client independently rolled from back to stomach on boppy pillow.

A: Client continues to show improvements in gross/fine motor developmental milestones and

play skills. Her balance in supported kneeling positions is increasing and she demonstrates the
ability to pivot. She rolled from supine to prone on an uneven surface. She still requires high
levels of assistance in crawling positions and transitions, showing inadequate strength and
coordination for these skills. Client is showing improvements in cognitive and fine motor
development, as demonstrated by her ability to hold two toys at once, showing signs of banging
two toys together, and her progression towards self-bottle feeding. Client will continue to
benefit from skilled OT services in the home to progress towards meeting developmental
milestones in areas of gross motor, fine motor, and play.

P: Client will continue skilled homecare OT 1x/week for 60 minutes to address motor and play
skills to progress towards achievement of developmental milestones.

LTG 1: In 6 months, client will independently creep for 6 steps to reach a desired toy, in 2/3
opportunities.
STG 1: In 2 months, client will independently maintain a quadruped position while reaching
forward bilaterally to play with toys for one minute, in 2/3 opportunities.

LTG 2: In 6 months, client will independently hold her own bottle during an entire feeding
session, in 2/3 opportunities.
STG 2: In 2 weeks, client will hold her own bottle to self-feed for 8 minutes, in 2/3
opportunities.