Name
TherAchieve
Pediatric and Adult Therapy Center 2nd Flr.. Antigua's Place, Gun-Ob, Lapu-Lapu City, Cebu
Contact no.: 09158111023
E-mail: [email protected]
Occupational Therapy Progress Report May 31, 2024
Mira Helena Tampus
April 19, 2019
Date of Birth
Age
Medical Diagnosis
Referring Doctor OT In-Charge Sessions
SUBJECTIVE:
5 years old
N/a
Dr. Kilantant MD
Dennis lan A. Delgado, OTRP
Monday 10-11AM,Thursday 9-10 AM, Friday 10-11AM
Mira was evaluated by me last March 21, 2024 with pertinent problems of ADLs, motor skills,
cognitive skills, communication skills, play and social participation. Upon evaluation, she was
seen to be dysregulated for the first weeks, however with the floor time approach she was able
to calm down and stopped crying. Mira is a smart child with difficulty in regulating her emotions,
she tends to whine and cry whenever an activity is given to her, however she is able to match
and identify various items, and also is able to perform gross motor related activities.
OBJECTIVE:
Below is a summary of Mira's current skills and occupations being targeted in
OT:
1. Child has difficulty in a) Adl participation
b) Play participation
c) Social participation
secondary to problems in Motor skills, Cognitive skills, Social Interactions skills, Communication
skills, work behavior, and voice and speech functions.
Typical OT session Includes
1. Routine commands/Obstacle Course/Movement based Activities/Gross Motor Skills Jumping
over hurdles
Crossing Over hurdles
Crawling
Hopping
Crossing Chairs
Crossing Balance beam
Climbing up and down ladders
2. Table top Axs, Fine Motor Skills, and Cognitive stimulation activities • Clay/Theraputty
Molding - Inserting pebbles
• Transferring clothespins
• Transferring clips
Lacing shapes
• School related activities/School readiness - tracing, writing, coloring • Story time
Arts and crafts
Problem solving activities - pattern puzzles, match it puzzles, alphabet puzzles Form boards -
Shapes, Letters, Animals, people, fruits, school
Where, what questions on common items/people and their uses
3. Social Participation activities
Movement activities + Taking Turns
Pass the ball activities
Social skills - Requesting from therapist, calling therapist, pointing to needs,
asking hands, "give" statements, and verbally expressing wants with 2-3 words. Group activities
- Dancing, Build a boat, build a tower
Language Facilitation: Info talk, Echo talk, Filling In, Obstacle, Expansion, Modeling
4. Emotional Regulation
Calming strategies
self talk
weighted blanket
breaking rigid patterns to facilitate transitioning
5. Behavioral Modification Techniques
Positive reinforcements
Negative reinforcements
Shaping
Modeling
Client Factors
I. Mental Functions
A. Higher-Level Cognitive
Concepts
Match
Sort
Recognize
Identify
Shapes
IND
IND
IND
Minimal Prompts
Color
IND
IND
IND
Minimal Prompts
Body Parts
IND
Moderate Prompts
IND
Minimal Prompts
Letters
IND
Moderate Prompts IND
Minimal Prompts
Numbers
IND
Moderate Prompts IND
Minimal Prompts
Common objects IND
Maximal Prompts
Moderate
Maximal Prompts
Prompts
Common people IND
Maximal Prompts
Moderate
Maximal Prompts
Prompts
Nam
Date
Age
Med ef
II.
B. Joint Attention
Evaluation
Upon Evaluation, Mira presented with absent joint attention even through free play
Present
Mira now has inconsistent Joint attention during activities, in which she
sometimes is able to attend to the activity at hand and also get easily distracted or whines.
C. Emotion
Evaluation
Mira immediately whines and cries when not given what she wants, or not being permitted to do
the things she wants.
Present
Mira now is excited and regulated upon entering the center. Mira still whines and cries when
doing one activity for a long time but can be co-regulated.
D. Experience of Self and Time
Evaluation
Mira would immediately run inside the center even if it is not her time yet, and would cry if not
permitted to enter, she would need maximal verbal and physical prompts to take off her shoes
and enter the center. Her Lolas would still try to calm her down by giving food or cellphone so
that she would start the therapy session.
Present
Now Mira is able to regulate herself and even get excited upon entering the center. She
remembers to take off her shoes before going in and gesturing "goodbye" to her lolas.
Neuromusculoskeletal and Movement-related Functions
A. Control of Voluntary Movement
a) Gross Motor Skills
i.
Mira can do the following independently
Crawling
Climbing
Running
• Walk up and down stairs
b) Fine Motor Skills
Able to transfer objects using tongs
Unable to lace
Unable to button
Performance in Occupations
1. Work Behaviors
1. Attention - Poor
2. Concentration -Poor
3. Impulse - Poor
4. Frustration tolerance- fair
II.
Social Participation
III.
IV.
Mira is able to gesture Hi and Goodbye given minimal to moderate verbal prompts. However
she would still do hand lead or pulling when indicating what she wants.
ADL Participation
Mira is able to Don and Doff shoes/slippers upon entering the center given minimal to moderate
verbal and physical prompts. She has poor overall skills in other areas of ADL
Play Participation
Mira is now able to do parallel play but mostly solitary play. She is able to use and play with the
toys in the intended way. She is now also able to imitate words given maximal prompts. She is
still not able to play with other children.
Others
Mira has been receiving Occupational Therapy services for approximately 1 month. For now her
basic skills has had good progress, however I observe that the behavioral strategies that I
recommended are still not applied fully at home that prevents her from improving work
behaviors.
Recommendations:
1. To continue Occupational Therapy thrice a week for 1 hour
2. Facilitation and improvement of work behaviors from Poor to Fair.
3. Collaborating with parents and all other people in the household to identify learning
opportunities at home to maximize learning of skill.
4. To recommend family to let Mira join in play group classes to maximize socialization. 5.
Create a sleep hygiene
6. Set Visual Schedule to help with her routines
It has been great working with Mira and her family during the course of his intervention. If you
have any questions regarding this report, please call me using this contact number.
09173200832 or email me at [email protected]
