PEMERIKSAAN OKUPASI TERAPI PADA PERKEMBANGAN ANAK

Nama :____________________ Nama Orangtua : ___________________

Jenis Kelamin :____________________ Alamat : ___________________
Tanggal lahir / umur :____________________ Nama Klinik /RS: ___________________
Diagnosis :____________________ Asal Rujukan : ___________________
Tanggal Pemeriksaan :____________________ Nama Terapis : ___________________

RIWAYAT SUBYEKTIF
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RIWAYAT OBYEKTIF
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(Hasil pemeriksaan ini menunjukkan level fungsi anak: BAIK / SEDANG / JELEK)

BERMAIN (posisi, skill, aktifitas favorit)

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SISTEM SENSORI
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VISION

KANAN KIRI
Focus
Alignment
Pursuit Horizontal
Vertical
Diagonal
Konvergen

Apakah terdapat gangguan penglihatan? Ketrampilan kompensasi? Kacamata?

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TAKTIL
KANAN KIRI
Stereognosis
Finger Location

Okupasi Terapi pada Pediatri

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AUDITORI
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OLFAKTORI
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PROPRIOCEPTIF
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VESTIBULAR / KESEIMBANGAN
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PEMERIKSAAN FISIK

TONUS Wajah AGA kanan AGA kiri Trunk AGB kanan AGB kiri
Normal
Tinggi
Rendah
Fluktuasi

Lingkup Gerak Sendi dan Kekuatan Otot Kanan kiri

Bahu
Siku
Lengan (supinasi/pronasi)
Pergelangan tangan
MCP
IP
Ibu Jari Tangan
Anggota Gerak Bawah

Tremor: Ringan_____ Kasar_____ Persisten_____ Intermitten_____ Intension_____

Reaksi Asosiasi:
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Reaksi Equilibrium:

Duduk bersimpuh lama _________________________________________________________________________

Berlutut _____________________________________________________________________________________
Berdiri ______________________________________________________________________________________
Reflek / Respon _______________________________________________________________________________
Alat Bantu ( adaptive devices, seating, splinting) ___________________________________________________
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Okupasi Terapi pada Pediatri

 PEMERIKSAAN OKUPASI TERAPI
PADA KONSEP, PERSEPSI DAN KOGNISI ANAK

Nama : ___________________________________
Jenis Kelamin : ___________________________________
Tanggal lahir / umur : ___________________________________
Klinik / RS : ___________________________________
Tanggal Pemeriksaan : ___________________________________

KONSENTRASI DAN ATENSI

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IMITASI DESAIN BLOK

(blok diberikan pada anak dalam jumlah pas / tepat)

Desain Kereta Jembatan Robot Pagar 3 Langkah Piramid

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2,5 3 3,5 4 4,5 5 5,5 6
rentang usia (tahun)

PUZZLES
(observasi kemampuan anak memecahkan masalah)

Form board (2 – 2,5 tahun) _____________________

Interlocking Puzzles jumlah biji puzzles 5 8 12 18

Rentang usia (tahun) 3 4 5 6

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UKURAN

_____Menunjukkan ukuran besar / kecil (2 - 2,5 th)

_____Menunjukkan mana yang lebih besar (2,5 – 3 th)
_____Mampu menunjukkan sekumpulan cangkir (2 – 2,5 th)
_____Mampu menunjukkan yang lebih panjang / pendek (3 – 3,5 th)

Keterangan: + = mampu
- = tidak mampu

Okupasi Terapi pada Pediatri

MENGHITUNG

Berhitung sampai Menghitung benda

_____2 -3 (<3 th) _____2 (2,5 -3 th)
_____5 (3 th) _____3 (3 – 4 th)
_____10 (3 – 4 th) _____6 (4 – 5 th)
_____13 (4 – 5 th) _____10 (5 – 6 th)
_____30 (5 – 6 th) _____20 (6 th)
WARNA

Menyesuaikan warna Menunjukkan warna Memberi label

_____1(2 -2,5 th) _____4 (3 – 4 th) _____1 (2,5 – 3 th)

_____4 (2,5 – 3 th) _____11(4 – 6 th) _____4 (4 – 5 th)
_____11 ( 3 – 4 th) _____10 (5 – 7 th)

Keterangan: + = mampu
- = tidak mampu

KESADARAN TUBUH (Body Awareness)

Mampu mengetahui bagian tubuh:

Jumlah Bagian Menunjukkan Memberi Nama Contoh Bagian Tubuh

Tubuh Bagian Tubuh Bagian Tubuh
4 _____(1,5 – 2 th) _____(2 – 2,5 th) Mulut, mata, hidung, kaki
12 _____(2 – 3 th) _____(2,5 – 3,5 th) Rambut, tangan, telinga, kepala,
lengan, tungkai, gigi, jari-jari.
22 _____(3 – 4 th) _____(3,5 – 5 th) Ibu jari tangan, ibu jari kaki,
perut, leher, punggung, dagu,
kuku jari, tangan, tumit.
25 _____(4 – 5 th) ______(5 – 6 th) Siku, pergelangan kaki, bahu

Menggambar orang:

Jumlah Bagian Tubuh Mampu Menggambar

_____2 – 5 (3 – 4 th) Tubuh, kepala, mata, mulut, anggota badan
_____5 – 9 (4 – 5 th) Bagian-bagian wajah yang lain, tungkai, kaki, lengan
_____9 – 12 ( 5 – 6 th) Rambut, Jari-jari tangan, baju
_____12+ (6 + th) Leher, tangan, pakaian lengkap

Mampu melengkapi 6 bagian puzzle tubuh (3 – 4 th)

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Okupasi Terapi pada Pediatri

 PEMERIKSAAN OKUPASI TERAPI
PADA PERKEMBANGAN MOTORIK KASAR ANAK

Nama : ______________________________
Jenis Kelamin : ______________________________
Tanggal lahir / umur : ______________________________
Klinik / RS : ______________________________
Tanggal Pemeriksaan : ______________________________

FUNGSI ANGGOTA GERAK BAWAH

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KAKI DOMINAN
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KOMENTAR UMUM
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AKTIFITAS MOTORIK KASAR

Berjalan 3 meter tidak pada garis (2 – 2,5 th) _____________

ke belakang Melangkah ke belakang pada garis 6 langkah _____________

Berjalan Sering jatuh, dapat berjalan dengan cepat, dapat

ke depan melangkah melewati halang rintang yang kecil _____________

Melangkah pada garis lurus (3 – 4 th) _____________

Melangkah ke depan 3 langkah _____________
Melangkah ke depan 2 meter pada garis(4 – 5 th) _____________

Meniti): Berdiri pada titian tanpa bantuan, berjalan ke depan

(<1 meter dengan bantuan ( 2 – 3 th) _____________
Melangkah ke depan tanpa bantuan, memakai kedua
lengan untuk keseimbangan (3 – 4 th) _____________
4 langkah ke depan, kedua tangan pada paha (4 – 5 th) _____________
Melangkah ke depan < 1 meter, kedua tangan
pada paha ( 4 – 4,5 th) _____________
5 langkah ke belakang ( 4 – 4,5 th) _____________

Berlari Berlari tanpa jatuh (1,5 – 2 th) _____________

Berlari perlahan dengan perubahan kecepatan(3 – 4 th) _____________
Lengan bergerak bergantian dengan tungkai( 4 – 4,5 th) _____________

Komentar: (kaku, pola berjalan flatfoot, dsb)

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Meloncat Meloncat 5 kali, dengan kaki sama ( 3 – 3,5 th) _____________

Meloncat 8 – 10 kali, dengan gerakan lengan dan
tungkai bergantian _____________
Meloncat 1 meter berirama _____________

Okupasi Terapi pada Pediatri

Berdiri pada 1 detik, kemudian berganti kaki lain (2 - 2,5 th) _____________
satu kaki 3 detik, kemudian berganti kaki lain (2,5 – 3 th) _____________
5 detik, kemudian berganti kaki lain (3 – 3,5 th) _____________
6 detik kaki kanan dan 6 detik kaki kiri (3,5 – 4 th) _____________
10 detik kaki kanan dan 10 detik kaki kiri (4,5 – 5 th) _____________

Melompat dengan 3 kali di tempat, kemudian ganti kaki lain (2,5 – 3 th) _____________
Satu kaki 5 kali ke depan dengan satu kaki, 3 kali ke depan
dengan kaki lain (3 – 3,5 th) _____________
8 kali ke depan dengan kaki kanan dan 8 kali ke depan
dengan kaki kiri (3,5 – 4 th) _____________

Melompat ke Melompati benda 32 cm – 40 cm (2 – 2,5 th) _____________

Bawah Melompati benda 36 cm – 48 cm (2,5 – 3 th) _____________
Melompati benda 48 cm – 60 cm (3 – 3,5 th) _____________
Melompati benda 64 cm ( 4 – 4,5 th) _____________

Melompat ke Benda 48 cm, dengan satu kaki (2 – 2,5 th) _____________

Depan Benda 52 cm – 60 cm, dua kaki bersama (3 – 3,5 th) ____________
Benda 32 cm ke depan pada satu kaki dan 24 cm ke
depan pada kaki lain (4 – 4,5) _____________
Benda 72 m, dengan kedua kaki bersama (4,5 – 5 th) _____________

Naik Tangga Kedua kaki bergantian dengan bantuan (2 – 2,5 th) _____________
Kedua kaki bergantian tanpa bantuan (3 – 3,5 th) _____________

Turun Tangga Dua kaki tiap langkah, dengan bantuan (2 – 2,5 th) _____________
Dua kaki tiap langkah, tanpa bantuan (2,5 – 3 th) _____________
Kedua kaki bergantian, tanpa bantuan (3 – 3,5 th) _____________

Melempar 5 – 7 kali gagal melempar secara akurat (2 – 2,5 th) _____________

(Bola Tenis) Memasukkan bola kedalam kotak ½ m2 dari jarak
1,5 m (3,5 – 4 th) _____________

Menangkap Bola Bola 12 cm dari jarak 1,5 m, lengan lurus (2,5 – 3 th) _____________
Bola 12 cm dari jarak 1,5 m, siku menekuk (3 -3,5 th) _____________
Bola tennis dari jarak 1,5 m, siku menekuk (3,5 – 4 th) _____________
Bola tennis dari jarak 2 m, siku disisi tubuh _____________

Menendang Bola Tanpa kehilangan keseimbangan ( 1,5 – 2 th) _____________

Menendang bola ke depan dari jarak 1,5 m (2,5 – 3 th) _____________
Menendang bola ke atas dari jarak 3 m (5 – 5,5 th) _____________
Memutar bola dengan telapak kaki sejauh 2,5 m (6-7 th)_____________
Menendang bola dengan tumit sejauh 1,5 m (6 – 7 th) _____________

Okupasi Terapi pada Pediatri

 PEMERIKSAAN OKUPASI TERAPI
PADA KEMAMPUAN MOTORIK HALUS ANAK

Nama : ___________________________________
Jenis Kelamin : ___________________________________
Tanggal lahir / umur : ___________________________________
Klinik / RS : ___________________________________
Tanggal Pemeriksaan : ___________________________________

FUNGSI ANGGOTA GERAK ATAS:

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TANGAN DOMINAN: ____________________________________________________________________

KEMAMPUAN MERAIH / MENGGENGGAM / MELEPAS / MENEMPATKAN BENDA:

(Kemampuan pada tipe menggenggam, observasi pada saat menggenggam benda kecil, balok/ blok dan pensil,
cross midline, melempar ke atas/ ke bawah, level kemampuan meraih, kontrol melepas dan menempatjan
benda, manipulasi tangan)
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Blok
Membuat Menara
Jumlah Blok :
1 2 3 4 5 6 7 8 9 10 11 12
umur: 1 1,5 2 3 4 5

Pegs
Besar(3 biji pegs pada pegboard pada usia 1,5 tahun ___________________________________________
Kecil: _______________________________________________________________________________

KETRAMPILAN BILATERAL

Meronce Manik-manik: Tipe benang: Gilig_____ Pipih______

Manik-manik besar (1 inchi) (2,5 th)__________________________________________
Manik sedang ( ½ inchi) (3 th)_______________________________________________
Manik kecil:______________________________________________________________

Melepas Manik-manik: Besar(2 – 2,5 th)__________________________________________________________

Kecil (2,5 th +) ___________________________________________________________

Menarik kertas: _____(1,5 - 2 th)_____ _____(2,5 – 3 th )_____

Hambatan: Supinasi / pronasi _______________________________________________________

Membalik halaman buku: dua lembar atau lebih sekali membalik (1 th)____________________
Satu halaman (1,5 – 2 th)_______________________________________

Menggunting: (observasi cara memegang kertas, kemampuan menggunting, control gerakan, perencanaan
gerakan, cara adaptasi, control arah menggunting, kemampuan yang dimiliki sebelumya)
Tipe menggunting: ____________________________________________________________________
Menggunting (1,5 – 2 th ________________________________________________________________
Menyilang kertas (2,5 – 3 th) _____________________________________________________________
Pada sebuah garis(3 – 3,5 th) ____________________________________________________________
Menggunting lingkaran (3,5 – 4 th) ________________________________________________________
Menggunting kotak (4 – 5 th) _____________________________________________________________

Okupasi Terapi pada Pediatri

KETRAMPILAN MEMAKAI PENSIL

Tipe memegang pensil: _________________________________________________________________________

Menulis nama: ________________________________________________________________________________
Scribble/ menulis spontan (1,5 th) _______________________________________________________________

Imitasi: I (1 th, 9 bln) ______ Mengkopi: I (2 th, 10 bln) ______

_ (2 th, 9 bln) ______ _ (3 th) ______
Ο (2 th, 9 bln) ______ Ο (3th) ______
+ (3 th) ______ + (4 th, 1 bln) ______
(4 th) _____ / (4 th, 4 bln) ______
∆ (5 th) ______ (4 th, 6 bln) ______
\ (4 th, 7 bln) ______
x (4 th, 11 bln) ______
∆ (5 th, 3 bln) ______

Komentar: Kualitas garis, control saat memulai dan menghentikan aktifitas, perencanaan gerakan, control
arah gerakan, mewarnai dan menggunakan adaptasi: ________________________________________________
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Okupasi Terapi pada Pediatri

 PEMERIKSAAN OKUPASI TERAPI ANAK
UNTUK AKTIFITAS KEHIDUPAN SEHARI-HARI

Nama : ______________________________
Jenis Kelamin : ______________________________
Tanggal lahir / umur : ______________________________
Klinik / RS : ______________________________
Tanggal Pemeriksaan : ______________________________

FAKTOR YANG MEMPENGARUHI AKS

(Tonus, kemampuan motorik, keseimbangan, proses penglihatan, motivasi, kognitif, dll)
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MAKAN

Metode makan: oral_______ non-oral_______

Kontrol motorik oral: _______________________________________________________________

Keadaan Umum (infeksi pernafasan, kualitas suara / bernafas, sekresi ludah)

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Nutrisi (kurang / kelebihan berat badan, kelelahan, keadaan kulit)

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Tipe dan Jumlah Makanan (tekstur)

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Posisi makan
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Lain – lain ( alergi, sensitifitas terhadap sesuatu, adanya gangguan kulit, dll)
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18 bln – 2 th
_____ berhenti minum dari botol dan minum dengan cangkir
_____ minum dengan cangkir, sedikit tumpah, tapi makanan tidak tumpah
_____ bisa makan dimeja dengan acak-acakan
_____ mengunyah dengan mulut tertutup
_____ menggigit makanan secara bertahap

2 th – 2,5 th
_____ tidak ada minuman yang tumpah dari mulut
_____ secara bertahap rahang membuka untuk makanan yang bervariasi ketebalannya
_____ mengunyah dengan rotasi
_____ minum dengan sedotan

2,5 th – 3 th
_____ makan sendiri dengan sedikit tercecer
_____ minum sendiri dari cangkir dengan sedikit tercecer
_____ menggunakan garpu untuk makan
_____ menuang air dari wadah yang kecil

3 th – 4 th
_____ mempunyai semua komponen gerakan dasar fungsi motorik oral
_____ mempunyai etika cara makan
4 th – 5 th
_____ mampu menyiapkan makanan sendiri

Okupasi Terapi pada Pediatri

 5 th – 6 th
_____ mampu membuat sereal sendiri
_____ memotong makanan dengan pisau

BERPAKAIAN

2 th – 2,5 th
_____ melepas kaos, baju dan celana pendek
_____ memakai dan melepas resleting

2,5 th – 3 th
_____ mencoba menalikan tali sepatu (biasanya tidak betul)
_____ tidak bisa mengancingkan kancing baju 1 cm
_____ memakai kaos, baju, jas/jaket (perlu bantuan untuk mengencangkan)
_____ melepas dan memakai kaus kaki

3 th – 4 th
_____ memakai sepatu secara mandiri (tidak perlu kaki yang betul)
_____ menarik baju keatas
_____ mengancingkan kancing 1 cm

4 th – 5 th
_____ mengancingkan kancing baju sesuai lubangnya
_____ memakai celana pendek dan melepas baju dan bisa membedakan bagian depan dan belakang baju
_____ menalikan sepatu dan memakai sepatu pada kaki yang benar

5 th – 6 th
_____ mengancingkan resleting di bawah secara mandiri
_____ menalikan tali sepatu

TOILETING

15 bln – 18 bln _____ mulai mengidentifikasi celana yang basah

18 bln – 2 th _____ mampu memberitahu bila merasa akan BAB/BAK
2 th – 2,5 th _____ antisipasi verbal bila ingin ke toilet
_____ dibiasakan ke toilet pada waktu tertentu
2,5 th – 3 th _____ control BAB/BAK tapi waktu belum teratur
_____ bisa pergi ke toilet dan melepaas celana sendiri
_____ bila pergi ke toilet terlalu lama
3 th – 4 th _____ control BAB/BAK pada malam hari
_____ membersihkan sendiri pantatnya dengan air/tisu
4 th – 5 th _____ mampu melakukan aktifitas toileting secara mandiri

BERDANDAN/ MENCUCI MUKA/ MANDI

2 th – 3 th _____ mencuci dan mengeringkan tangan tanpa bantuan

_____ mampu membedakan antara lap yang panans dan dingin
3 th – 4 th _____ membersihkan dan mengeringkan wajah (perlu diingatkan)
_____ membersihkan hidung bila disuruh
_____ merapikan rambut
4 th – 5 th _____ mampu mengatur suhu air untuk mandi
_____ membersihkan hidung tanpa bantuan
_____ menyisir rambut
5 th – 6 th _____ menggosok gigi secara mandiri
_____ mandi tanpa bantuan

Keterangan: + = mampu
- = tidak mampu

KESIMPULAN
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Okupasi Terapi pada Pediatri

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PERMASALAHAN
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PRIORITAS MASALAH
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PROGRAM TERAPI
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Okupasi Terapi pada Pediatri

HOME PROGRAM
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EVALUASI
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Okupasi Terapi pada Pediatri