OCCUPATIONAL THERAPY

PROGRESS/TREATMENT NOTE

Clients Name: XXX Supervising Therapist: Jessica Kahn, MS, OTR/L

Student Therapist: Rachel Swan, OTS
Date: 7/5/17 Goals Updated: # Units: 4
Clients Goals:
1. XXX will engage in tactile and/or messy media play for 10-12 minutes with no adverse reactions, 100 pecent of the
time.
2. XXX will introduce 1-2 new foods every 1-2 weeks, having them consistently remain in diet over a 4 month period.
3. XXX will don and doff shoes, socks, pants, and a shirt with min A, 3/4 trials.
4. XXX will utilize a fork and spoon to feed herself, with age appropriate grasp and minimal spillage, 75% of the time.

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)
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)
Education: Formal Education- Participating in academic (e.g., math, reading, degree coursework), nonacademic (e.g.,recess, lunchroom, hallway), extracurricular
(e.g., sports, band, cheerleading, dances), and vocational (prevocational and vocational) educational activities.
Informal Education- (beyond formal education e.g. Identifying topics and methods for obtaining topic-related information or skills).
Informal personal education participation- Participating in informal classes, programs, and activities that provide instruction or training in identified areas of
interest.
Work: (employment interests & pursuits, employment seeking & acquisition, job performance, retirement preparation and adjustment, volunteer
exploration & participation).
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 Skills Sensory Skills Social Skills
Core Stability Manipulation Temperature Pressure Engages/Approaches Others
Endurance Coordination Hearing Taste Concludes/Transitions/Takes turns
Position/Aligns Motor Planning Vestibular Smell Communicates (verbal/non-verbal)
Joint Mobility Reaching/grasp Tactile Pain Looks/Turns (Makes eye-contact)
Joint Stability Reflexes Proprioceptive Visual Emotional Expression
Tone & Strength Controlled Discrimination Modulation Physical behavior (regulates movement, position,
Movement touch)
Other Other Other

Processing/Cognitive/Mental functions: Visual Perceptual/Visual Motor Skills

Attends Experience of self & time Oculomotor Skills Object Perception
Memory Emotional regulation Visual Attention Eye-hand Coordination
Sequences Tasks Energy & drive Visual Discrimination Copying Shapes
Executive Functions Notices/responds to cues Visual Motor Speed Spatial Relations
Chooses/Uses materials Pacing of activities Visual Memory Form Constancy
Locates/Gathers materials Organizes Materials Depth Perception Visual Acuity
Adjusts/Accommodates Navigates Environment Visual Closure Sequential Memory
Initiates/Continues/Terminates Orientation to self, other, Figure Ground Visual Closure
Tasks/Activities time & place
Other 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

Subjective Data (Home Progress/Comments):

Accompanied by: Mother
Affect: Happy, regulated
Health Status: Good

"I need help" (with putting shoes on feet).

Objective Performance Data (ratio: #correct/ # trials and % accuracy, count: # of occurrences in a time frame, # min on task, etc.)
Progress M: Mastered (>80%) GP: Good Progress (60-79%) P: Progress (40-59%) E: Emerging (<40%) NA: Not
Assist I: Independent MinA:75% ModA:50% MaxA:25% Dep: Dependent - 0%
Prompt 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

(What you did; Skill that was targeted; related to what (Measurements of the targeted skill listed in the description, and any other notes relevant to the goal or performance)
function)
Parent Discussion to check in on XXX's XXX's mother stated that XXX fed herself a waffle with age-appropriate utensils during this past week at
progress at home home. She also stated some concerns about XXX's sensory seeking and behaviors that are not age-
appropriate at home. Mom stated that XXX is exhibiting some concerning "regressive" behaviors such
as wanting to go in her baby brother's crib and on his play mat, as well as increased defiance.

Warm-Up Activity: XXX was able to doff her socks and shoes I. When she put her socks and shoes back on she required
XXX was asked to remove her socks and Mod physcial assistance to get socks over toes, un-strap her shoes, place her foot in the shoe, and pull
shoes and then changed into a "princess the tab on her shoe before velcroe-ing it back on.
dress"
Targeted Skills: don/doffing shoes, fine motor
strength/coordination

Activity 1: blowing pom poms out of hands XXX was able to blow 1/5 pom poms off of her hand with air from her mouth, however she is still using
Targetes Skills: oral motor coordination, her teeth and making an "F" sound when blowing out air. During the other attempts, she tilted her hand
feeding skills so that the pom pom would fall out of it. She needed Mod VP to use only her mouth to get the pom
poms out of her hand.

Activity 2: Playing with Play Doh, using tools
to make shapes, and age-appropriate
scissors with a spring assist to cut Play Doh
into pieces
Targeted Skills: fine motor
strength/coordination, FM skills needed for
feeding & self-care, tolerance of tactile play
Activity 3: Walking through the hallway to the
restroom outside of the clinic to wash hands
Targeted Skills: emotional regulation,sensory
regulation
XXX needed Max physical A to hold the scissors correctly and HOH assistance to keep her forearm in
the correct position while cutting. After a demonstration, she was better able to complete the open/close
movement of the hand. XXX S rolled the Play Doh in a ball and pressed it flat on the table multiple times
during this activity.
XXX was resistant to having the headphones placed on her head, however, she tolerated them and kept
them on with Mod VP from the therapist. She did not hesitate to walk out of clinic however, once down
the hall her anxiety increased and she said "it's dark". When the therapist lead her into the restroom,
XXX was visibilty anxious, but walked in with Mod VP /reassurance from the therapist. The headphones
were then taken off, with preferred music playing through the loud speaker. XXX was able to tolerate
surrounding noises (faucet, towel dispenser). She needed Mod VP to wash her hands in the sink and
activate the paper towel dispenser to dry her hands.

Home Program: Have XXX use feeding utensils during meal times, simple behavior/reward chart
Family/Care Giver Education (verbal, written, demonstration, homework assigned): Verbal
Family/Care Giver Understanding of Education (verbal, demonstration): Verbal
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?)
During discussion with XXX's mother, the therapist addressed plans with the parent to help reduce defiant behaviors at home.
During the session, XXX showed improvement of her emotional regulation skills when going into the restroom to wash her hands. The use of auditory
input that she was in control of helped reduce her anxiety. This week, she was better able to control her response to auditory hypersensitivty from
surrounding noises. Although she continued to demonstrate anxiety, she was able to manage it well enough to finish washing her hands and leave the
restroom with assistance from the therapist. XXX continues to make slow but steady progress towards her goal areas. Her decreased fine motor skills
and sensory defensiveness still cause her to need active assistance from the therapist, which decreases her independence in age-appropriate tasks
such as dressing, feeding, and self-care.

Goal and Outcome Progress

1. XXX showed progress towards this goal by finishing the tactile media play with min adverse reactions. She also has

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

show progress by using auditory input that she is in control of to help her regulate her emtions around "scary" sounds with
guidance from the therapist. This is still not something that XXX does spontaneously or I
2. Still having difficulty eating novel foods, saying "I can't". Showed improvement in this area today.
3. Showing progress towards doffing clothing (was able to remove the dress, only needing assistance to unbutton the
back and maintain balance). XXX continues to need Mod physical A to don socks and shoes, but is able to doff them I

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?)
Continue sensory motor play and feeding therapy to help increase XXX's participation in daily activities.

Continue Discharge Other: Next Appointment: 7/10/17

Student Therapist Signature: Rachel Swan, OTS
Supervising Therapist Signature:

Division of Occupational Therapys LIFE SKILLS CLINIC

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