Progress Report Overview

Student: Andrea Padilla

Activity: Remy Williamson

Start Time: 01/16/2024 13:24:44

End Time: 03/26/2024 17:48:50

Total Time: 25:37:21

Actions

Note at 03/26/2024 17:48:10

Remy Williamson Documentation
Student: Andrea Padilla
Activity Start: 01/16/2024 13:24:44
Activity Completion: 03/26/2024 17:48:50
Activity Completion: 25:37:21

Patient Data

Patient: Remy Williamson DOB: 11/23/2009

Age/Sex: 14 yo MR#:

Notes

Note at 01/16/2024 13:09:40

Occupational Therapy (OT) SOAP Note

Basic Information

Date:

01/16/2024 13:09:40

Author:
Current User

Location:
Valley View Therapy Center

Patient name:

Remy Williamson

Diagnosis

Ataxic cerebral palsy

Precautions/medical history:

PMH:
No relevant past history
Precautions/contraindications:
No known drug allergies, G-tube for feeding

Medications: Is currently taking medication

Treatment date:

2/27/2024
Start time:

9:00am

End time:

11:00am

Subjective

Occupational Profile: Remy is a 14-year-old boy diagnosed with ataxic cerebral palsy (ICD code G80.4), characterized by bilateral
spastic quadriplegia. His condition presents with shaky extremity movements, and his incoordination is amplified by stress,
excitement, or effort, resulting in poor control over prominent movements. This significantly affects his ability to handle objects or
complete simple tasks. Remi utilizes a GI tube for feeding and a wheelchair for mobility. For communication, he relies on PEC board,
which he finds limiting in his ability to communicate. He has never received any physical or speech therapy. Remy’s primary
concerns relate to his communication as he is transitioning to high school. Remy would like to increase his communication skills so
that he can participate in school and social activities.
Environment:
Remy lives with his dad, sister, and mom in a single-story home. In school, he receives no accommodations or support from
paraeducators; instead, his peers assist him. Despite being treated well, with no bullying reported, Remi has no friends in school
and does not engage in extracurricular activities. He experiences difficulties communicating with teachers and requires a long time
to complete homework.
Occupational History:
Remy enjoys being in nature and has a keen interest in gardening, particularly watering plants. He also enjoys watching TV and
movies, writing letters, and reading. These activities suggest a preference for engaging in tasks that provide him with a sense of
accomplishment and connection with the environment and his interests.
Support:
Remy’s support includes his loving and supporting family who are actively involved in his care, Para for mobility at school.

Objective

Clients’ vitals are-

Heart rate: 86 b/min
O2 level- 96mm/hg
BP- 130/70 mm/hg
RR- 18 breaths per minute
Client did not report any pain when asked on a lickart scale.
Physical Environment
Clients' lives in a single-story house with 3 bedrooms and 2 bathrooms.
Exterior entrances and exits
Walkways: Walkway from driveway to front door paved, uncluttered. ramp to entryway; no handrails present.
Lighting: Overhead lighting present in covered porch to entryway.
Threshold: Ramp from porch to interior of home.
Locks/knobs: Deadbolt and lever-style knob easy to reach; 36 inches from ground level.
House numbers visibility: House numbers clear from street; lighting above numbers at night. Accessibility around bushes/shrubs:
bushes and shrubs pruned appropriately to provide uncluttered access to walkways.
Doorbell: Doorbell located on left side of doorjamb, lit and operable.
Door width: measures 36 inches, door in good condition.
Gates: no gates at location.
Interior doors, stairs, hallways
Lighting and controls: overhead lighting; controls on both ends of hallway easily accessible.
Door thresholds: smooth transitions between carpet and tiled surfaces.
Door width: 28 inches all interior doors, in good condition.
Knob and hinge types: all interior doors have lever handles and plain butt hinges, in good condition.
Floor space around entryways: interior of entryway cluttered with recycling bins, shoes, throw rug.
Floor surface and level changes: low pile carpet throughout home except for wet areas (kitchen, bathrooms, and laundry). No level
changes.
Hallway width: 36 inches.
Types of stairs: None.
Rail(s): None.
Clutter: Personal belongings lining walls in living areas present trip hazard.
Bathroom(s)
Lighting and controls: Overhead and vanity lighting in master and guest bathrooms. Controls easily accessible.
Tub/shower and controls: Both master and guest baths have tub/shower combination with curtain and liner. Temperature control
knobs and diverter pull operational.
Sink/basin and controls: Temperature control knobs and drain stopper operational.
Under sink hot water pipes covered: Enclosed in cabinet.
Reaching overhead shelf / below basin: No overhead shelf in front of basin; sliding drawers for toiletries located to left and right of
basin cabinetry.
Toilet height: 16 inches floor to seat.
Flush control: On left side of cistern.
Space for caregiver assistance: WC and tub shower located in separate rooms; 4 sqft floor space in front of toilet; 20 sqft floor space
in front of tub.
Ground fault circuit interrupter (GFCI) outlets: Located near basin.
Kitchen:
Lighting and controls: Overhead, incandescent. Controls easily accessible.
Sink and counter heights: Double bowl, stainless steel drop-in kitchen sink and counter located 34 inches from floor.
Wall and floor storage shelf heights: Lowest shelf 12 inches from floor; highest shelf 77 inches from floor.
Under sink hot water pipes covered: Enclosed in cabinet.
Surfaces for hot items near range/stove: 12 inches countertop to right of stove.
Location and condition of stove controls: Controls along back of stove; white=on-black markings beginning to wear.
Ground fault circuit interrupter (GFCI) outlets: To left of sink.
Living, dining, bedroom
Furniture heights to allow sitting/standing/transfers: Sofa and armchair covered with clean laundry; cushions overstuffed and
heavily worn.
Rugs with non-slip pads: Corners of area rug under dining table curled; no non-slip mat beneath.
Chairs with armrests: Four dining chairs, with armrests.
Operation of environmental controls (lighting) from bed, chair, and sofa: Lighting controls located on opposite wall from seating
area.
Access to closets: Coat closet and bedroom closets with slide type doors.
Window operation: Sash type vinyl windows propped open with wood dowels.
Laundry
Access to wash/dryer: Laundry detergent and basket located on floor in front of washer and dryer.
Operation of washer/dryer: Controls along back of appliances.
Access to cleaning supplies: Placed in a bucket, mops and brooms lean against wall next to washer.
Safety
Smoke detectors: In kitchen and both bedrooms; battery charge light on.
Carbon monoxide alarms: Located in living room and in hallway between two bedrooms.
Fire extinguishers: present in garage.
Thermostat controls: Located in living room near lighting controls.
Water heater temperature settings >120 degrees: 120 degrees
Emergency plan (fire, gas leak, power outage): Two exits from house (front and back); both bedrooms have egress through window.
Workstation Evaluation
Desk Evaluation:
Height: Desk height ranges from 27 inches to 34 inches, adjustable to accommodate Remi's specific wheelchair and comfort.
Surface Area: Adequate surface space is there to accommodate his learning materials, communication device, and any assistive
devices. A width of 46 inches and depth of 40 inches.
Leg Space: There is enough clearance for Remi’s legs and the wheelchair. A knee clearance of 27 inches in height, 30 inches in width,
and 19 inches in depth is measured.
2. Chair/Wheelchair Space:
Wheelchair Fit: Remy’s wheelchair can easily fit under the desk, with no obstacles to his approach or departure.
3. Computer and Assistive Device Placement:
Monitor Height and Distance: The computer monitor is placed at eye level, approximately 20-28 inches from Remy’s eyes. The top of
the screen is slightly below eye level.
Input Devices: Keyboard and mouse or any alternative input devices like buttons are within easy reach, requiring minimal effort to
use. Adjustable trays are present to use these devices optimally.
Communication Devices: Any communication aids are easily accessible and positioned to facilitate use without causing strain or
requiring excessive movement.
4. Environmental Considerations:
Lighting: Adequate lighting is there to reduce eye strain, with options to adjust based on task requirements.
Acoustics: The noise level in the workstation area is conducive to concentration and communication, especially important given
Remu’s reliance on auditory cues in his communication.
Problematic Occupational performance
Remy's primary challenges in occupational performance stem from his ataxic cerebral palsy, which significantly impacts his
communication abilities and physical independence. These challenges have a profound effect on his activities of daily living (ADLs),
instrumental activities of daily living (IADLs), social participation, and educational activities.
Communication: Remi faces considerable difficulties in expressing himself, which hinders his ability to interact socially, participate in
school, and live independently. His reliance on non-verbal gestures and the limited options provided by the PEC board restricts his
ability to engage fully in conversations or express complex ideas and emotions.
Mobility and Physical Independence: Remy requires moderate to maximum assistance with most ADLs and IADLs, reflecting
significant obstacles in carrying out basic self-care tasks such as dressing, grooming, and feeding, as well as managing household
responsibilities like cleaning and financial tasks or school homework. His dependency on a wheelchair for mobility and challenges
with using a walker for short distances further curtail his physical independence.
Social Participation: Although he benefits from a supportive environment, Remy's restricted communication skills and physical
dependence present barriers to forming friendships, participating in extracurricular activities, and fully engaging in community and
family events. These challenges may become more pronounced as he transitions to high school, potentially increasing his sense of
isolation. Educational Activities: In the educational domain, Remi struggles with both communication and physical tasks, which
manifests in prolonged periods spent completing homework and difficulties interacting with teachers and peers. The lack of
adequate accommodations exacerbates these challenges, potentially impeding his academic performance and participation in
school activities.
Problematic Body Functions and Body structure
Motor and Movement Functions:
Muscle Functions: Remy exhibits significantly reduced muscle power, affecting his ability to perform movements against gravity,
especially in terms of both gross and fine motor skills.
Muscle Tone Functions: The presence of spasticity in his muscles leads to increased muscle tone, which can restrict movement and
flexibility, contributing to difficulties in initiating and executing movements smoothly.
Involuntary Movement Reaction: Remy's cerebral palsy results in poor coordination and shaky movements, further complicating his
motor control. Neuromusculoskeletal and Movement-Related Functions:
Joint Mobility and Stability: Remy's bilateral spastic quadriplegia likely impacts his joint mobility and stability, affecting his ability to
maintain or change positions independently.
Gait Patterns: His ability to walk, even with a walker, is limited to short distances, indicating impaired gait patterns and endurance.
As his core is not stable it affects his digital stability.
Mental Functions:
Attention Functions: The effort required to manage his physical limitations may impact Remy's ability to sustain attention, especially
in environments that are not adapted to his needs.
Emotional Functions: The frustration and potential social isolation resulting from his communication and mobility challenges could
impact his emotional well-being.
Body Structures
Structure of the Nervous System: The cerebral palsy affecting Remy stems from damage to or abnormalities within his brain,
impairing his ability to control movement and maintain posture and balance.
Structure of the U/L Extremities: The spasticity affects the muscles and joints of both his arms and legs, limiting fine and gross
motor abilities and contributing to his reliance on a wheelchair for mobility.
Additional Structures Related to Movement: The muscle stiffness and joint stability issues may also affect his spine and trunk
control, important for maintaining balance and performing various ADLs.

Assessment
Summary: Remy is a 14 year with ataxic cerebral palsy. His main concerns are related to his communication difficulties. This is
especially important to him as he is transitioning into high school. Remy is currently using a PECS system for communication. This is
no longer effective for him as this limits him on the variety of words he can try and communicate. Another challenge with this
current communication system is that due to his shaky movements it is often difficult to precisly point to the picture/word he wants
to say. Mom reports that she makes her best guess when trying to understand what Remy wants to communicate, however this
takes much thinking and is more difficult for others who do know Remy as well. These communication challenges create frustration
for Remy. He is motivated to find a communication system that works for him. When presenting the joy stick, and different types of
switches these all were found not to be effective as his shaky movements made it difficult for him to select the icons he wanted to
select. The eye Gaze worked best for him and he was able to effeciantly communicate his needs.

Functional Problem Statement:

Remy has difficulties with communication. He requires maximum assistance with communication tasks due to his challenges of
precision and motor control. Remy's current system of communication of PECS limit the amount of communication options, is not
efficient, and is not portable. In order to communicate Remy needs someone to place the PECS on a surface for him.
Rehab Potential:
Remy demonstrates great Rehab potential. Remy has a strong family support who are actively involved in his care. Remy also
demonstrates a high level of motivation to improve his communication. He is highly motivated to do this as he is transitioning to
high school and would love to build relationships with his peers. Remy's cognitive abilities are typical for someone of his age which
will facilitate learning new methods of communication. Another strong rehab potential is his love for reading and writing. Remy
hopes to one day become a writer. Developing a strong communication system that works for him will allow him to achieve his
personal goals.
Potential Benefits to Receiving Interventions:
Potential benefits to receiving interventions include, improved communication skills, increased independence in tasks, improved
social interactions with family and peers, increased quality of life, improved academic performance by allowing him to actively
participate in classroom, Increased confidence and self esteem, and reduced frustration by being able to clearly and more easily
express his needs and preferences.

Potential Risks Associated with not Receiving Interventions:

Potential risks associated with not receiving interventions include, social isolation due to the challenges of communication,
academic challenges such as limited participation in classroom discussion which can impact his learning, impact on mental health
due to social isolation and feelings of frustration, limited participation in group tasks, and dependency on others to make choices
for him. This also limits his independence and ability to express his wants and needs.

Plan
 Overview of Intervention Plan: Remy will receive occupational therapy services at his house 3 times per week for 45 minute sessions
for the next 12 months. The reasoning for this amount of sessions and the length of services is because Remy presents with a
complex case. Remy will require a significant amount of training on how to use the communication device. Remy's past experience
with communication technology is very limited as he was using a paper system. The client also presents with muscle spasticity
making this a more complex case. Because of muscle spasticity, the client will have to be trained in proper seating and position to
encourage proximal stability for distal mobility. The clients environment will also need to be addressed and provide proper
education and training for him to effectively use his communication device. Proper ergonomics will need to be addressed since the
client spends most of his time in his wheelchair. Proper head control will also need to be addressed to allow the communication
device to be used effectively.
Frequency: Remy will receive occupational therapy services
Duration: Sessions will last for 45 minutes
Location: Sessions will take place at Remy's residence
Foci of Services: The foci of services include improving familiarity and proficiency with the Dynavox communication system to
increase his communication skills as he transitions to high school.

Targeted Outcomes:
Outcome 1: Increase Proficiency with Dynavox. Improving his proficiency with the dynavox will allow him to use the communication
device independently and efficiantly, which will improve his communication
Outcome 2:
Enhancing Social Communication skills will allow Remy to engage more effectively in social interactions leading to an increase in
participation in school and personal life as well as social activities.
Goals:
LTG 1: By march 2025, Remy will independently use the Dynavox to initiate or engage in social interactions at least 8/10 times per
day across multiple settings without needing assistance or experiencing difficulties navigating the dynavox.
STG 1: By July 2024, Remy will engage in 50 percent of classroom discussions with 5 or less errors in using the dynavox to in the
classroom setting.
STG 2: By November 2024 Remy will initiate 10 conversations daily with his peers or family using the dynavox with minimal
difficulty.
Approach to Intervention: the approach to intervention that I will be used in Remy's case is the Establish, Restore approach. This is
because the goal with Remy is to establish a skill which is using the dynavox to increase his communication skills. since this skill has
not been developed it would be considered establish.
Type of Intervention: The type of intervention would be Training. This is because Remy will be educated on a new device but what
makes this training is that he will be trained to enhance his skills rather than understand the device. The training would include how
to effectively use the dynavox to initiate conversations, request, and contribute to discussions using the dynavox.

LTG 2: By March 2025, Remy will maintain conversations by for up to 30 minutes using the dynavox in 50 percent of interactions
across multiple settings.
STG 1: By July 2024 Remy will engage in conversations with family and peers for 10 minutes without assistance in 50 percent of all
opportunities.
STG 2: Remy will engage in conversations for 10 minutes using the dynavox with new people with minimal errors and no assistance.
Approach to Intervention: Create/Promote would be the approach being used in this intervention because this approach focuses on
enhancing performance. Since Remy already had the skill of communication with a PECS board, his communication is being
enhanced with the dynavox.
Type of Intervention: The type of intervention would training Remy on how to use the dynavox to engage in conversations. The
training might also include education but what separates this from the education is that he will actively be trained on how to use it
to enhance his skills.

Charges:

97165 - OT evaluation
Other
If other, describe

92605- Evaluation of prescription of non speech generating augmentative and alternative communication device, face-to-face with
the patient, first hour, 97535- self care/home management training and compensatory training, meal preparation, safety
procedures, and instructions in use of assistive technology devices/adaptive equipment, direct one-on-one contact

Electronic signature:

Andrea Padilla and Ajaybir Kalkat