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PROGRESS/TREATMENT NOTE
Clients Name: O
Date: 12/03/15
Visit #: 8
Clients Goals:
1 Within 4 months, O will improve fine motor coordination and precision skills to cut out simple shapes
(3 diameter circle and 4 sized square) staying within of the line with 80% accuracy on 4/5 trials.
2 Within 4 months, O will improve fine motor precision and eye/hand coordination skills hold a writing
utensil with a tripod grip and write his first name and numbers 1-10 (letters and numbers being 1 in
size) with correct line adherence, number/letter formation , size and spacing with 80% accuracy on 4/5
trials.
3 Within 4 months, O will improve fine motor precision and eye/hand coordination skills hold a writing
utensil with a tripod grip and write upper case ABCs (letters 1 in size) with correct line adherence,
letter formation , size and spacing with 80% accuracy on 4/5 trials.
4 Within 4 months, O improve manual dexterity and bilateral hand coordination to button/unbutton 4/4
buttons on an item he is wearing (buttons being -1/2 in size) in under 90 seconds on 4/5 trials.
5 Within 4 months, O will perform fine motor & writing academic activities at school with good accuracy
in the allotted time frame with good compliance and without frustration or temper outbursts as
observed/reported by classroom teacher.
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)
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 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
Temperatur
x Pressure
x Core
x Manipulation
x Engages/Approaches Others
x
x
x
Stability
Endurance
Position/Alig
ns
Joint Mobility
x
x
x
Coordination
Motor
Planning
Reaching/gr
asp
e
Hearing
Vestibular
x Tactile
Taste
Smell
x Concludes/Transitions/Takes turns
x Communicates (verbal/non-verbal)
Pain
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
x Joint Stability
x Tone &
Strength
Reflexes
x Controlled
Movement
Other
x Propriocepti
ve
x Discriminati
on
Visual
x Modulati
on
Other
x Emotional Expression
x Physical behavior (regulates
movement, position, touch)
Other
Processing/Cognitive/Mental functions:
Attends
Oculomotor Skills
x Object Perception
Memory
Visual Attention
Sequences Tasks
Executive Functions
x
x
x
x
Visual Discrimination
Visual Motor Speed
x Eye-hand
Coordination
x Copying Shapes
x Spatial Relations
Chooses/Uses
materials
Locates/Gathers
materials
Adjusts/Accommodate
s
Initiates/Continues/Ter
minates
Tasks/Activities
Other
Visual Memory
x Form Constancy
Organizes Materials
Depth Perception
Navigates
Environment
Orientation to self,
other, time & place
x
x
Visual Closure
x
Figure Ground
Visual Acuity
x Sequential Memory
Visual Closure
Other
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
Session Data
Subjective Data (Home Progress/Comments):
O and mother arrived for OT today. O seemed a little reticent at first, but warmed up as we
discussed the activities planned for the day. A visual schedule was used to introduce him to
the plans for the session. O demonstrated overall good attention to the activities today, even
when one activity was combined with another student. He was able to focus and finish the
activity. O enjoyed the Star Wars theme of the activities and seems more willing to
participate when theme is used. Caution should be used though due to the need to refocus his
attention a few times due to his desire to discuss Star Wars.
Accompanied by: Mother, Mother accompanied us to the area that the activities were
taking place.
Affect: Excited
Health Status: Well
Objective Data (ratio: #correct/ # trials and % accuracy, count: # of occurrences in a time frame, # min on task, etc.)
Progres
s
Assist
Prompt
M: Mastered (>80%)
GP: Good Progress (60-79%)
NA: Not Addressed
I: Independent
MinA:75%
ModA:50%
MaxA:25%
P: Progress (40-59%)
E: Emerging (<40%)
Dep: Dependent - 0%
S= spontaneous (w/o request) I= Independent (w/request, no other prompt) VP= Verbal Prompt M= Model (imitation)
R=refused/unable
Intervention Description
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
bilateral coordination
progress in the legibility of the alphabet. His legibility is still around 60-65%. After missing a week of
interventions (due to Thanksgiving) he regressed on his proper letter formation, going back to forming his
magic c letters using a clockwise formation rather then counterclockwise. O required less prompts to
refocus attention on tasks, and had less times that he lost focus on the task at hand. According to what
happened this session, next session we will refocus on proper formation of race car letters, on bilateral and
hand/eye coordination.
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?)
Next session we will focus on correct letter formation of race car letters using a counterclockwise
formation. We will also reintroduce the fireman letters. Hand/eye coordination, bilateral coordination, and
fine motor control will be the focus during these written activities as well as cutting and pasting activities.
A list of gross motor activities that mom can do at home with O to promote the proper formation of the
race car letters will be give to her as homework. I will encourage her to do at least a couple of the items on
the list before the next session.
x Continue
Dischar
Other:
ge
Student Therapist Signature:
Supervising Therapist Signature:
Name:
Colton Savage
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
Session/SOAP Note #:
8
Session Date:
SOAP note is a note about what actually happened in a session. Should be written in past tense.
Should state the childs name (not initial or student) Its for insurance to review when they audit
they need to have documentation to justify them paying for the service and also need to review
for progress so they will authorize continued visits. It needs to document skilled intervention,
measurable/observable relevant data (both subjective and objective), document & assess
progress towards goals, and then plans for continued sessions.
Criteria
Examples
4. Subjective Session
Data Complete: Always
need to have a t least a
Brief narrative about what
happened at home, progress,
concerns, homework
feedback, also what
Meets
Expectatio
ns
.75 Pts
Outstandi
ng
1 pt.
x
x
x
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
5. Interventions
Description: accurately
described & analyzed - This
section justifies to
insurance why they are
going to pay for therapy.
What about the activity is
therapeutic and why they
would pay you to do this
versus if a parent, teacher or
caregiver were doing this with
the child. This doesnt have to
be long but it has to contain
a brief description of the
intervention with what skills
you are targeting towards
what functional outcome.
(HINT: Combine simplified
version of activity description
from treatment plan with
anticipated outcomes from
treatment plan)
6. Objective Data :
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
3. -Doff clothing: S, I
9. Assessment: Accurate
analysis of data/observations
made during session
Professionally and concisely
written. DO NOT restate
objective data here. You
summarize what objective
data means and then state
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
x
Days Late
On Time
x
10.25
OCCUPATIONAL THERAPY
PROGRESS/TREATMENT NOTE
Comments: