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NAME DATE OF BIRTH DDD SC DIAGNOSIS Child REPORTING PERIOD 04/03/2005 PHYSICIAN Support Coordinator THERAPIST Fine Motor Delay, Sensory Processing Disorder 03/09/2008 - 05/09/2008 Dr. Physician Therapist A, MS, OTR/L COTA B, COTA/L

Subjective: Attendance 3/9/2008 5/9/2008 No Show / Cancellation Dates None Duration 1 Hour/week Home-based Collaboration with other providers Home based PT


Background Summary: Over the past three months, Child has made great progress in his occupational therapy skills. He is now giving better eye contact, attending to task for up to 30 minutes, focusing on activities his therapist asks him to complete, and taking more initiative in his daily activities. At the beginning of services, Child was noted to have some behavioral problems focusing on task, often throwing himself on the ground or crying, but these behaviors have such decreased tremendously. He is writing more clearly, coloring within the boundaries of lines, and attempting to write his name. Child still has some trouble with initiating dressing and bathing activities. He does need redirection often and cueing to complete the task. His sensory processing skills have also improved, tolerating various types of textures, movement, and activity, which helps him calm his nervous system. Because of Childs great progress, It is highly recommended that Child continue occupational therapy services one time per week. Objective: Goals and progress as follows: 1. Home program developed and in place with family training and education to support the following goals. Goal is in progress with no current change. Goal in progress. Childs family has been instructed and offered ideas to help calm Child are able to calm down when he becomes frustrated. These activities consists of joint compressions, deep pressure, vestibular input such as swinging in a blanket, rolling or jumping on a therapy ball, and other activities that offer proprioceptive input into his daily diet. Continue goal. 2. Child will bathe himself with verbal cueing only, 80% of the time. Goal in progress. Child still needs cuing to wash himself in areas that are of need and to complete the process of washing his hair thoroughly getting all the soap out. Continue Goal. 3. Child will increase his fine motor precision by demonstration of in hand manipulation such as buttons, snaps, and other small objects with 80% accuracy. Goal in progress. Child still has a difficult time with refined fine motor tasks such as buttoning small buttons and using a refined pincer grasp to pick

up small objects. He can get frustrated, but with verbal cueing and encouragement, he is able to continue trying with the task. Continue goal. 4. Child will demonstrate the ability to place his socks and shoes on the correct feet 100% of the time. Goal Achieved. 5. Child will use a functional grasp on his writing utensil when coloring, writing his name or drawing. Goal Achieved. 6. Child will dress his upper and lower body with minimal assistance 80% of the time. Goal Achieved. Assessment: Justification of continued therapy: Child continues to make great progress with his OT goals and objectives. He is participating more independently and taking on more roles of independence in play and work situations. It is strongly recommended that Child continue to receive occupational therapy one time per week to continue his progress with all areas mentioned above. Discontinue goals 4-6 Continue goals 1-3 Plan: New goals: Child initiates the dressing processing and complete both upper and body dressing with only verbal cueing, 3/5 trials. Child will increase fine and hand musculature to manipulate small objects such as unscrewing tops to bottles, placing toys together, buttoning objects, etc. with 3/5 trials. Child will write his name with attention to placement of letters on paper with accurate spacing and sizing, 3/5 trials. Recommendations: Continue treatment: Scope/Frequency of treatment: Model: Duration of treatment:

Yes 60 minutes per week Home-based therapy For a minimum of 12 months, with goals and objectives to be reviewed in 2-3 months time.

Home Program Recommendations: 1. Strengthening exercises for hands: play with play-doh, glue, modeling clay. Allow Child to get involved with mixing, kneading, stirring, and rolling dough when cooking or baking in the kitchen. Spray bottle play/squirt gun play -outside or in the bathtub. Clothespin activities and games are great for hand strengthening and can be used in various ways. 2. Schedule a variety of vestibular and proprioceptive activities throughout Childs day like bouncing on the trampoline, bike riding, swinging, blanket games (like rolling up in a blanket). It is best to schedule these activities before requiring him to focus on a difficult task such as handwriting. 3. Allow Child extra time when getting dressed to attempt buttons and snaps and only give him as much support as he requires before frustration sets in. 4. Play games such as tag, catch, hot potato, Simon Says, London Bridges, Hokey Pokey, to involve Child in interactive listening games which require body awareness.

5. Determine the times when Child is most likely to break down into tantrums (ie when he is tired, hungry/thirsty, bored, after too much TV time, etc) and schedule time in his corner with books so that he can relax. 6. Write stories with Child that encourage him in tough situations, allowing him to put his feeling into words and on the paper. Make him the main character of the story. Then encourage him to read these when he is having a difficult time with each area. 7. Play strengthening games that involve exercises for Childs trunk muscles (eg. crab walk, wheelbarrow walk, sit-ups on therapy ball). If you have any further questions, please contact at xxx-xxx-xxxx. DIGITALLY SIGNED COTA B, COTA/L Certified Occupational Therapist Assistant

DIGITALLY SIGNED Therapist A MS, OTR/L Occupational Therapist/Licensed Cc: File, Family, Physicians, DDD