OCCUPATIONAL THERAPY PROGRESS NOTES

(February 2019 to November 2019)

Name: LUCIDO, Vince Joel

Age/Sex: 2 8/12 years old / Male
Diagnosis: -
Referring MD: -

Vince was seen bi-weekly for one-on-one therapy sessions from February 2019 up to
present. Co-management with teacher Irish Guanlao was done. Good attendance to
therapy is noted.

OBJECTIVE INFORMATION

SENSORY PROCESSING
Goals Achieved Partially Not Achieved
Achieved
1. Vince will tolerate hand-over- ü
hand assistance within 5-10
secons
2. Vince will tolerate wet/slimy ü
textures such as clay and slime
without avoidane
3. Vince will tolerate changes in ü
posture such as when being
bounced on a vestiball

WORK BEHAVIORS
Goals Achieved Partially Not Achieved
Achieved
1. Vince will attend to a 5-minute ü
activity without being distracted
 2. Vince will continue engaging
with activities even when ü
experiencing difficulty Note: Prompted to
continue at times
3. Vince will tolerate maximal ü
physical assistance during
structured activities

FINE MOTOR SKILLS

Goals Achieved Partially Not Achieved
Achieved
1. Vince will remove squigz
independently without release of ü
grasp
2. Vince will assume, maintain and
use tip-to-tip pinch given ü
moderate physical assistance
3. Vince will assume, maintain and ü
use three jaw chuck pinch given
moderate physical assistance

VISUAL PERCEPTUAL SKILLS

Goals Achieved Partially Not Achieved
Achieved
1. Vince will match colors
independently such as when ü
putting circles on pegs
2. Vince will match shapes ü
independently such as when
presented with a shape sorter

LISTENING SKILLS
Goals Achieved Partially Not Achieved
Achieved
1. Vince will perform 1 step verbal ü
command given visual cues
2. Vince will perform 1 step verbal ü
command without repetition

SOCIAL COMMUNICATION SKILLS

Goals Achieved Partially Not Achieved
Achieved
1. Vince will eliminate crying when ü
being handed over to therapist
during session
 2. Vince will initiate play by ü
choosing a toy he prefers
3. Vince will imitate actions with a
toy during play ü

SELF-CARE SKILLS
Goals Achieved Not Achieved
1. Vince will remove socks ü
independenlty
2. Vince will remove velcro closure ü
of shoes independently
3. Vince will tolerate holding spoon ü
during feeding

ASSESSMENT
The following improvements were noted:
o Sensory processing, specifically in modulating input in the tactile and vestibular
system
o Work behaviors, specifically attention span, frustration tolerance and following
instructions
o Fine motor skills, specifically in-hand manipulation skills and use of fine
prehension patterns, grip and pinch strength
o Visual-perceptual skills, specifically matching
o Listening skills, specifically following 1 step verbal commands
o Social-communication skills, specifically reduction of separation and stranger
anxiety

No regressions were noted.

 PLAN AND RECOMMENDATIONS

It is recommended that Vince continue to receive occupational therapy services to

further address sensory processing, work behaviors, fine motor skills, visual perceptual
skills, listening skills, social skills, communication skills and self-care skills.

Should you have any question regarding this document, do not hesitate to contact
the undersigned at mobile number 0917 829 2985 or e-mail at
nkvgarcia@gmail.com.

Report prepared by:

Nina Karmela V. Garcia, OTRP

Occupational Therapy Consultant
PRC License No. 003537