OCCUPATIONAL THERAPY

LIFE SKILLS CLINIC

PROGRESS AND TREATMENT NOTE

Client's First Name: For confidentiality purposes Date of Service: November 12, 2020 Supervising Therapist: BJ
“client” Woolston

ICD10 Code(s) and Diagnoses Start/End Time: Total Minutes in Student Clinician: Megan
Q07.00 Arnold-Chiari syndrome without spina 11:00- 11:40 Therapy: Wilson
bifida or hydrocephalus 40 minutes

Clients Goals Addressed this Treatment Session:

Goal (Target Behavior/Distal Measure)
1. Within 6 months, client will copy her name, demonstrating 80% accuracy for letter formation and
letter placement 4/5 opportunities
2. Within 6 months, client will cut out a circle, demonstrating good mid-range position with no more than
¼" deviation off of the line 4/5 opportunities
3. Within 6 months, client will attend to a non-preferred task for 10 minutes with no more than 3 VC
4/5 opportunities
4. Within 6 months, client will full-body dress with Min A 5/7 opportunities

S: Dad reported that dressing outside of therapy is almost as difficult, although she is getting better at
straightening out her clothes independently.
O: The client completed a handwriting activity. She wrote her name 2x with a tripod grasp, sitting and
leaning on her forearms with her face close to the paper. She independently formed the letters "A, l, i,"
correctly. She required max VC such as line guides and on formation for "c, e." She required min VC for
placement of "A" and mod VC for letter placement of "lice." She was also noted to put big spaces
between the letters at the end of her name. She practiced "e" again with no line guides and wrote it very
large. She was given a box to write "e" in again and was given min VC for letter formation. The third
time she wrote "e," she drew her own tracing dots and formed the letter correctly. The client then
completed a simple hidden picture with simple shapes, sitting on the edge of her chair, leaning on her
forearms, with her face close to the paper. She found 4/6 independently and required Min A to find the
other 2 shapes. She independently colored the hidden shapes, using a tripod grasp with 90% accuracy and
within 1/8" deviation. Lastly, The client participated in dressing task. Dad held up the shirt backward,
and she independently identified the need to reorient it and created a "window." She required Min A to
put one arm in the sleeve, to pull the shirt down, and to straighten. She placed her legs in the shorts on
while standing independently. She required a VP to pinch the waistband to pull them up.
A: The client shows improvements in letter formation for writing her name. Although she prefers
provided visual cues, she is able to draw her own tracing dots for the letter "e," demonstrating she knows
how it should be formed. However, she is still showing difficulty with letter placement and control. She
continues to demonstrate poor posture during seated table tasks due to deficits in core strength,
affecting her ability to stabilize and complete tasks effectively. The client’s visual perceptual abilities
are improving as she was able to find very similar shapes to the one she was looking for during the
hidden pictures. However, continued practice is recommended. Based on parent report, dressing is still
difficult
for the client though she continues to improve with motor planning during dressing, especially with
shorts. Attention and possibly endurance deficits are impacting her difficulty with attending to non-
preferred tasks, and she still requires tangible motivators to engage. Continued skilled OT services are
recommended.
P: The therapist instructed the client’s father on how he can make certain activities easier or harder for
her, specifically during the hidden pictures activity. He also explained to her father the process they will
follow for improving handwriting. Now that she is improving on letter formation working on control is
next, and then letter size and placement.

Billing: 3 units of 97530

Megan Wilson OTS 11.25.20