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  • FW Soap Note Fall 2020

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    The client received occupational therapy to address delayed fine motor skills. During the session, the client required many verbal and visual cues to write letters in the air and trace letters with their finger. The client also needed cues to cut shapes and copy a sentence. The assessment found the client has impaired attention, memory, and coordination which impacts their ability to participate in educational activities. The plan is for the client to continue occupational therapy twice a week to work on writing, cutting, and fastening skills. The short and long term goals are for the client to improve their letter writing, cutting, and grasping abilities over the next few weeks and school year.

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    fw soap note fall 2020

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    The client received occupational therapy to address delayed fine motor skills. During the session, the client required many verbal and visual cues to write letters in the air and trace letters with their finger. The client also needed cues to cut shapes and copy a sentence. The assessment found the client has impaired attention, memory, and coordination which impacts their ability to participate in educational activities. The plan is for the client to continue occupational therapy twice a week to work on writing, cutting, and fastening skills. The short and long term goals are for the client to improve their letter writing, cutting, and grasping abilities over the next few weeks and school year.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    57 views2 pages

    FW Soap Note Fall 2020

    Uploaded by

    api-581690140
    The client received occupational therapy to address delayed fine motor skills. During the session, the client required many verbal and visual cues to write letters in the air and trace letters with their finger. The client also needed cues to cut shapes and copy a sentence. The assessment found the client has impaired attention, memory, and coordination which impacts their ability to participate in educational activities. The plan is for the client to continue occupational therapy twice a week to work on writing, cutting, and fastening skills. The short and long term goals are for the client to improve their letter writing, cutting, and grasping abilities over the next few weeks and school year.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Subjective:

    Client stated they do not like to write and that they can not write the full alphabet.

    Objective:

    Client was seen for 20 minutes in their classroom on 10/13/2020 to address delayed fine motor skills.

    First, client wrote the letters “A”, “B”, and “C” in the air with BUE and required mod A in order to

    facilitate the correct movement of the limbs. Client traced the same letters with their index finger in a

    tray of salt and needed 3 verbal and 5 visual cues in order to complete. Next, he cut out a circle and a

    square with scissors and required 6 verbal cues to stay on the lines. Client then identified the sentence “I

    am going to play as Kirby” and practiced copying the sentence down, requiring 7 verbal cues to ensure

    letter legibility. Lastly, client finished session by tracing letters on the IPAD, which provided a visual cue

    for each letter.

    Assessment:

    Client demonstrates impaired attention, memory, and ability to heed, shown by the need for verbal and

    visual cues throughout the session. In addition, client has difficulty with eye-hand coordination and fine

    motor control, including griping and manipulating objects such as scissors and pencils. Client’s

    impairments negatively impact his ability to perform and participate in education based activities.

    Plan:

    Client will continue to receive skilled occupational therapy services 2x/week for 15 minutes each

    session, at Dry Creek Elementary School. OT will address attention, memory, eye-hand coordination, and

    fine motor control by working on education based activities such as writing, cutting with scissors, and

    fastening fasteners.

    LTG and STG 1:

    Within 1 IEP year, client will copy 5 sentences independently with 80% accuracy in letter formation,

    sizing, spacing, and line adherence, in 4/5 opportunities.


    In 4 weeks, client will write the entire alphabet in upper and lower case letters with 80% accuracy in

    letter formation, sizing, and line adherence, in 3/5 opportunities.

    LTG and STG 2:

    Within 1 IEP year, client will cut out a circle and square with scissors independently within ¼ in. of line,

    with 80% accuracy, in 4/5 opportunities.

    In 4 weeks, client will cut out a straight line with scissors independently within ¼ in. of line, with 80%

    accuracy, in 5/5 opportunities OR In 3 weeks, client will demonstrate thumbs up grasp of scissors

    independently while cutting in 5/5 opportunities.

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