Occupational Therapy

Progress/Treament Note

Client’s Name: Supervising Therapist: Kristine Barrios

Student Therapist: McCall Halvorson
Date: 11.3.2017 Time In/Out: 3-4 # Units: 4
Clients Goals Addressed:
Goal (Target Behavior/Distal Measure) Proximal Measures GAS Scale
(Distal)
1 In 4 months, Client will Recognize -1,+1, -1
recognize emotional/psychological/physical cues
that he is unable to focus, implement
emotional/psychological/physica coping strategies to maintain focus
l cues that he is unable to focus on classroom task
and implement independent
coping strategies to maintain
focus on classroom task for 15
minutes with 100% accuracy on
4/5 trials.

2 In 4 months, Client will write a 90% legibility for line adherence, 90% -1,-1,+1,-1

5-sentence paragraph legibility for letter spacing, 90% for

size
demonstrating 90% legibility for
line adherence, letter spacing,
and size on 4/5 consecutive
opportunities for 4 consecutive
data collection sets.

3 Date: Date:

4 Date: Date:

5 Date: Date:

Clients Occupations Treated: (check all that apply)

ADL’s/Self Care: (bathing, showering, toileting & hygiene, swallowing/eating, feeding, Personal device
care & managing personal belongings, personal organization ,functional mobility, personal hygiene and
grooming)
x 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)
Work: (Employment interests & pursuits, Employment seeking & acquisition, job performance,
retirement preparation and adjustment, volunteer exploration & participation).
x Education: formal education- Participation in academic 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 participating- Participating in informal classes, programs and
 Occupational Therapy
Progress/Treament Note

activities that provide instruction or training in identified areas of interest.

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 Sensory Skills Social Skills
Skills
X Core X Manipulation Temperatur Pressure Engages/Approaches Others
Stability e
X Endurance X Coordination Hearing Taste Concludes/Transitions/Takes turns
Position/Alig X Motor x Vestibular Smell x Communicates (verbal/non-verbal)
ns Planning
Joint Mobility Reaching/gr Tactile Pain Looks/Turns (Makes eye-contact)
asp
X Joint Stability Reflexes x Propriocepti Visual x Emotional Expression
ve
x Tone & x Controlled Discriminati Modulati Physical behavior (regulates
Strength Movement on on movement, position, touch)

Other Other Other

Processing/Cognitive/Mental functions: Visual Perceptual/Visual Motor Skills
Attends Experience of self & Oculomotor Skills Object Perception
time
Memory x Emotional Visual Attention Eye-hand
regulation Coordination
Sequences Tasks Energy & drive Visual Discrimination Copying Shapes
x Executive Functions x Notices/responds to Visual Motor Speed Spatial Relations
cues
Chooses/Uses Pacing of activities Visual Memory Form Constancy
materials
Locates/Gathers Organizes Materials Depth Perception Visual Acuity
materials
Adjusts/Accommodate Navigates Visual Closure Sequential Memory
s Environment
Initiates/Continues/Ter Orientation to self, Figure Ground Visual Closure
minates other, time & place
Tasks/Activities
Other Other
 Occupational Therapy
Progress/Treament Note

Session Data
(S)
Mom reports client has had a better week at school. Also reports blood sugar has not been stable for the
last couple of weeks due to pancreas changing. Mom also reported she is meeting with client’s teacher this
week to check in on how he is doing in school and if requested modifications are being made.

Objective Data (ratio: #correct/ # trials and % accuracy, count: # of occurrences in a time frame, # min on task, etc.)

Progres M: Mastered (>80%) GP: Good Progress (60-79%) P: Progress (40-59%) E: Emerging (<40%)
NA: Not Addressed
s
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
(O) Intervention Description and Objective Performance Data
Client was seen in the Like Skills Clinic for 60 minutes to address emotional regulation and handwriting.
Client participated in training and education on tools and strategies for emotional regulation throughout
the day both at home and at school. He was able to independently identify tools that were appropriate or
inappropriate for each setting with 100% accuracy following initial directions. He remained on task with
minimal verbal cueing for attention throughout the activity. He also required increased time to complete
task. He wrote down multiple strategies on small paper with ~85% legibility.

Mom was administered the COPM results are as follows (Reported just as mom responded, including
reasoning for behaviors):
Self-Care
Personal Care- Client is a very picky eater. Mom reports he prefers mostly spaghetti, chicken
nuggets, German pancakes (puff pancakes pizza and sometimes crackers. He does NOT like meat and will
often gag while eating it. Client’s blood sugar is currently not controlled very well due to recent changes in
his pancreas. He is able to monitor blood sugars independently, but often doesn’t. Mom would like to
possibly implement a morning schedule because of the impact the low blood sugar has on his mood in the
mornings.
Picky eating: importance-8, performance- 3, satisfaction-2
Blood sugar management: importance- 10, performance- 5, satisfaction-7
No concerns with functional mobility or community management
Productivity
Paid or unpaid work- No concerns
Household management- Does not keep room clean and will often have a breakdown when asked to
do chores. (25% time, ‘breakdowns’ are very big and disruptive.) Mom is fine, as long as his mess is kept to
his room. Step-father is very concerned with toys being picked up everywhere at all times.
School and or play- Client frequently fights with younger sister (3 y.o.). Possibly due to low blood
sugar and not having taken ADHD medication yet. Mom reports client often times says he doesn’t like her
in his space. Client has also been experiencing problems with transitioning at school. He recently had a
book he really enjoyed reading and when asked to transition (often to tasks he does not enjoy- “5
’something’”) will begin to cry. Client enjoys reading homework but when homework involves spelling, he
needs a warning that it is coming or will lose emotional control.
Chores: Importance- 6, Performance- 5, satisfaction-6
Younger sister relationship: importance- 10, performance-3, satisfaction-1
School transitions: importance- 10, performance- 5, satisfaction- 3
Leisure
Quiet Recreation, active recreation and social participation- No concerns reported. Mom reports he is
often very well behaved when with others (specifically at friends houses).
(A) Assessment
Though Client only required 2 vc to remain on task, he appeared to have some difficulty with focusing to
complete activity as seen by requiring increased time for task completion. He wrote with decreased
legibility today due to the size of the paper and proximity of the lines as well as being focused on content
of his writing instead of focusing on the quality of his letter formation and overall legibility. He
 Occupational Therapy
Progress/Treament Note

demonstrated good insight to appropriate/inappropriate tools and strategies across multiple settings. In
the past he has been given these strategies but struggles to recall them without a visual reminder. Further
training and follow-up is recommended to ensure carryover and integration of skills.
Following COPM with mom, it seems client is experiencing multiple difficulties, which could be explained by
uncontrolled blood sugar. This is likely exacerbated by the client’s very picky eating habits. Picky eating
habits may be influenced by the clients history or diabetes and gluten intolerance. Other variable
contributing to emotional dysregulation may include, unstructured environment and the client not having
his own possessions that others are not allowed to play with, allowing them to take things that are
important to him. Client has the ability to do all tasks required of him, but often lacks the volition required.
This information was previously unknown to the therapist and could greatly impact original therapy goals,
if addressed.
(P) Plan
Client will continue to receive skilled OT services 1/wk for 60 minutes to address concerns with emotional
regulation, handwriting and eating preferences. Client could benefit from emotional regulation exercises
based in home-like situations to improve interaction with younger sister. Client could also benefit from
incorporating expanding food preferences activities in treatment sessions. Lastly, client may benefit from a
schedule (specifically for snacks) to help better maintain blood pressure, which will likely improve
emotional regulation and increase occupational participation. Client could also benefit from instruction of
importance of regulating blood sugar.

Based on results of COPM goals will be updated to include:

Within four months, Client will implement Zones tools when experiencing emotional dysregulation with
younger sister to increase appropriate social participation, with min VC in 4/5 trials.

Within four months, Client will monitor blood sugar, daily, morning and evening to improve health
maintenance, independently, 5/7 days over three consecutive weeks.

Within two months, client will try at least one bite of all food placed on his plate at each mealtime, 4/5
trials with minimal verbal cues.

Home Program:
Family/Care Giver Education: - Verbal - Written - Demonstration
-Homework Sent
Family/Care Giver Understanding of Education: -Verbal -Demonstration

x Continue Dischar Other: Next Appointment:

ge 11.10.2017
Student Therapist Signature:
Supervising Therapist Signature: