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CONFIDENTIAL

OCCUPATIONAL THERAPY PROGRESS REPORT

Name: Lee Jia Hwei (Janet)

DOB: 29th December 1989 Age: 24 years old

Date of evaluation: Completed reassessment on 9th November 2015

Occupation: Working from home Caregiver: Joyce Moi & Lee Tiam

Diagnosis: Intractable epilepsy and learning difficulty.

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Narrative progress note:

Janet attended scheduled occupational therapy session since February 2014. Reason of referral was to
assist in motor coordination and others areas which related were contributing to her behavioral concern
and academic difficulties. She is currently attending OT session mostly twice a month to complete
RehaCom Cognitive Training until now. Her mother was actively participated during the session and has
done a comprehensive home training as suggested by therapist.

Self Help Skill / Instrumental ADL Skills

Janet independently in most of her self-care activities but need minimal assistance and supervision in
performing most of instrumental activity of daily living such as preparing meal, shopping, using
transportation and community mobility.

Methods of Evaluation/Training

The Chessington O.T. Neurological Assessment Battery (COTNAB) test was administered on second
time to measure any significant neurological improvement after a year of therapy session. From the first
finding, Janet was suggested to attend The RehaCom cognitive training (RehaCom) for her complete
cognitive therapy meanwhile she undergo the comprehensive therapy from her behavioral vision therapist
for her visual aspects.

PREPARED BY:
NUR RAFIDAH MOHAMED
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Assessment of COTNAB Results:

In summary, Janet was less confused on re-assessment. Some improvements were recorded in Ability in
Visual Perception and in Following Instruction, and in Time on Sensory Motor. Although it is only
slightly changes, but it stills considerable an improvements, particularly in Visual Perception, but not in
Constructional Ability. However, she remains impaired in most areas. Difficulties in shape recognition
and spatial orientation were still evident in Constructional Ability and Ability to follow Written and
Spoken Instruction.

She has shown some improvement and developed a few strategies to compensate for her
difficulties. It is felt that she would continue to benefit from Behavioral Visual Therapy and Visual
Perceptual Skills Training.

Results of the COTNAB reassessment were as follows:

Ability Time Overall Performance

Visual Perception
I. Overlapping Figures Within normal limit Impaired Borderline
II. Hidden Figures Impaired Impaired Severely impaired
III. Sequencing Below average / borderline Impaired Impaired

Constructional Ability
I. 2D Construction Impaired Below Average Impaired
II. 3D Construction Impaired Impaired Severely impaired
III. Block Printing Impaired Impaired Severely impaired

Sensory Motor
I. Stereognosis / D Below Average Impaired Impaired
Tactile
ND Below Average Impaired Impaired
Discrimination
II. Dexterity D Within normal limit Impaired Impaired
ND Within normal limit Impaired Impaired
B Within normal limit Impaired Impaired
III. Co-ordination D Impaired Above Average Impaired
Within normal
ND Impaired Impaired
limit
Following Instructions
I. Written Instruction Impaired Impaired Impaired
II. Visual Instruction Below average / borderline Impaired Impaired
III. Spoken Instruction Impaired Impaired Severely impaired
Note: Blue font – improve; red font – decrease

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The comparison between previous performance and current performance were shown in the picture
below.

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Summary of overall reassessment.

Before After Before After

Correct response Time
SECTION 1
24/32 26/32 9’13” 17’56”
Visual Perception
Comments: In hidden figures, patient may neglect details of a design but shown better in sequencing
activities. Need to do more activities in term of size discrimination and spatial relationship. Keep it up.
Overall patient had shown improvement in this section.

SECTION 2
Constructional 5/23 4/23 21’47” 13’51”
Ability
Comments: In 2D and 3D construction, patient may have mild of ‘ataxia’ or constructional dyspraxia due
to poor quality drawings with jagged and unintentional lines. Meanwhile in block printing, she had shown
improvement. Please refer to the table below.

SECTION 3 Although in term of ability is still under impaired Rt Lt Rt Lt

performance but generally she had shown better Hand Hand Hand Hand
Sensory Motor understanding and analyzing the problems in the
better way. 8’18” 8’58” 6’29” 6’27”
Comments : Tasks may again need to be incorporated in the treatment program to promote both speed
and accuracy of coordination, perhaps focusing on rhythmical movements.

SECTION 4 Although in term of ability is still under impaired 68’15” 38’16”

performance but generally she had shown better
Following understanding and analyzing the problems in the
Instructions better way.

Comments :

In Written Instructions – patient get easily frustrated as a task increases in complexity, this may be
reflected in other areas, particularly when learning new skills or faced with unfamiliar challenges.

In Visual Instructions – become easily confused when presented with complex information, particularly
of an unfamiliar nature. Tasks may need to be broken down into component sections and approached in
systematic order. Patient had better performance in visual instructions compare to written and spoken
instructions.

In Spoken Instructions – may neglect details of pictures and confuse with pictures which quite similar to
each other’s.

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Constructional Ability – Before After Comments

Block Printing
1. Had shown improvement in term of
spatial relationship

2. Had shown improvement but still

shapes offset from one another

3. Still had large space between shape

4. Had shown improvement with minor

error. Had spatial rotation of blocks

5. Had major error due to misjudge of

space relationship and shapes

Comments: May exhibit difficulty with scanning, shape and size discrimination, spatial relationships or may have problems of dyspraxia nature.

Result Training using the RehaCom® Cognitive Training:

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Modul Results Comments

Reaction Behaviour
 Attending 5 sessions in this
module.
 Cumulative hours training in
this module were 1 hour and 43
minutes with total of training
was 63 circles.
 Had shown improvement with
best performance at level 7
which resulting 88% for correct
response.

Attention & Concentration

 Attending 3 sessions in this module.

 Cumulative hours training in this
module were 44 minutes with total of
training was 9 circles.
 Had shown improvement with best
performance at level 24 which resulting
20 error within 32 trial of training.

Figural Memory

 Attending 3 sessions in this module.

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 Cumulative hours training in this

module were 51 minutes with total of
training was 35 circles.
 Had shown improvement with best
performance at level 9 which resulting
23 incorrect items over 45 items of
training.

Memory of words

 Attending 5 sessions in this module.

 Cumulative hours training in this
module were 1 hour and 20 minutes
with total of training was 35 circles.
 Had shown improvement with best
performance at level 30 which resulting
10/50 for correct response.

Shopping

 Attending 3 sessions in this module.

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 Cumulative hours training in this

module were 50 minutes with total of
training was 7 circles.
 Had shown improvement with best
performance at level 18 which resulting
3 incorrect items over 10 items that
requested. Also involving dictions
concerning money.

Saccadic Training

 Attending 4 sessions in this module.

 Cumulative hours training in this
module were 50 minutes with total of
training was 29 circles.
 Had shown improvement with best
performance at level 28 which resulting
4 incorrect response over 12 numbers of
stimulation.

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Plan a Day

 Attending 5 sessions in this module.

 Cumulative hours training in this
module were 1 hour and 41 minutes
with total of training was 24 circles.
 Had shown improvement with best
performance at level 19 which number
solution target 1/3.

Visuo-motor Coordination

 Attending 2 sessions in this module.

 Cumulative hours training in this
module were 34 minutes with total of
training was 11 circles.
 Stills at level 1 with 32% time out.

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Visuo-constructional Ability

 Attending 12 sessions in this module.

 Cumulative hours training in this
module were 2 hours and 51 minutes
with total of training was 23 circles.
 Had shown improvement with best
performance at level 18 which resulting
number corresponding trials 17/93.

Outcome:

From the sessions, it has a positive effect on the client’s well-being and helps to improve quality of life. This leads to increased self-confidence
and self-esteem and to better vocational opportunities.

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CONFIDENTIAL

SUMMARY

Janet has shown a satisfactory progress in some of the activities that has been taught during therapy
session. After almost 2 years undergoing occupational therapy in UKM OT Clinic, she shows some
progress but seems still struggles in motor planning, performing complex gross motor skills and following
a series of instructions. Currently, she has better attention span during the sessions and able to tolerate
changes in plans or expectations without becoming upset; coping skills are improved.

Janet still need to continue her OT session to enhance and maintain her modulation, improve gross and
finer motor skills and readiness to engage in more challenging task as well as to improve organization of
task and behavior. Simulation on grouping activity would be beneficial for her to encourage more
interaction between peers; as well as to improve her social skill among peers to meet her age
appropriateness in socialization skill.

RECOMMENDATIONS:

It is recommended that Janet stills continue receiving occupational therapy services to enhance and
optimizing her components skills regarding visual-motor concerns, as they are stills impacting her
performance in learning process and her ability to organize and complete task given independently.
Techniques are aimed at improving ideation and planning. Execution is assumed to follow:

1. Motor

a. Postural dyspraxia – use whole body motor patterns, such as total flexion, total extension,
rotation, and gross diagonal rotary patterns. Activities include going through an obstacle
course or tunnel on a scooter board and aiming an object to knock down a tower.

b. Dyspraxia on verbal command – speak slowly, use simple phrases and ask the child to
verbalize what is to be done and what was done after the activity.

c. Constructional dyspraxia – may be combined with postural activities to reset the obstacle
course or rebuild the tower.

d. Design copying dyspraxia – practice with tracing, dot to dot, outlining, or coloring hidden
figures.

2. Cognitive – help the child select and plan activities by modeling or demonstrating, asking questions,
offering solutions or suggesting alternatives (work toward independent problem solving).

3. Interpersonal – involving patient more in group activities that are challenging but can be completed
successfully to develop positive self-image and better communication skills among others.

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4. Leisure – leisure activities should improve as praxis skills improve. The parents or care giver may
need to assist the patient in exploring leisure interests.

Prepared by:

Nur Rafidah Mohamed

Occupational Therapist
School of Rehabilitation of Sciences
Faculty of Health Sciences
University Kebangsaan Malaysia

ummi_ot@yahoo.com
03-26878056

10th December 2015

PREPARED BY:
NUR RAFIDAH MOHAMED
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