SAMPLE PEDIATRIC SOAP NOTE

Student’s name: Sophia Cortez, OTS Client: Child Pt 2

Clinical Supervisor: Emily Mike Date: 02/18/25
Age: 5 Draft #: 1
Diagnosis/ICD-10 Code: Other Disorders of Psychological development/F88, CDK13-related
disorders/Q87.8, Unspecified lack of coordination/R27.9

OCCUPATIONAL PERFORMANCE ISSUES ADDRESSED: Decreased communication skills, decreased

dressing skills, decreased social participation, and decreased play skills

INTERVENTIONS
Occupations: Dressing, toileting
Activities: Under-table strengthening activity to improve bilateral coordination, core stability, and fine
motor grasp strength, Prone number retrieval task to facilitate motor planning, sequencing, and sustained
attention, Under-table tracing activity to promote bilateral hand use and visual-motor integration,
Handwriting task with spatial awareness cues to improve letter formation and boundary awareness,
Dressing-based obstacle course integrating lower-body dressing movements (placing rings around ankles)
within a gross motor circuit to develop motor planning, sequencing, proprioception, and bilateral
coordination.
Methods to Support Occupations: Structured verbal and tactile cueing for dressing and toileting
independence, Visual and gestural prompts to encourage bilateral hand use and task sequencing, Gross
motor balance-based activities to support postural stability and motor coordination, positive reinforcement
and structured redirection techniques to support frustration tolerance, emotional regulation, and maintained
attention, promoting determination and adaptability during challenging tasks.
Education & Training: None

S: Client stated, "I couldn’t wait to play." The physical therapist (PT) reported that the client had difficulty
maintaining attention during their session but was able to catch the ball 18 consecutive times while standing
on a balance beam, indicating progress in postural control and hand-eye coordination when engaged in a
preferred activity. However, the classroom teacher reported that the client struggles with redirection and
often becomes upset when said "no" or when making mistakes during classroom activities. The teacher also
expressed concern about the client’s difficulty with dressing, specifically with donning and doffing socks and
shoes independently, as the client frequently places socks on incorrectly and puts shoes on the wrong feet.
These difficulties suggest deficits in motor planning, proprioception, and sequencing, impacting functional
independence in dressing.

O: Length of Session: 60 minutes

A strengthening activity was implemented with the client lying under a table on a wedge seat for postural
support, with legs elevated on a chair to facilitate core engagement and postural stability. A jump rope was
tied along the legs of the table, with clothespin letters and numbers attached. The therapist called out specific
letters and numbers for the client to retrieve using a pincer grasp with the right hand while stabilizing the
rope with the left hand, promoting fine motor precision, bilateral coordination, and visual scanning. This
activity addressed fine motor control, working memory, and sustained attention by requiring the client to
search for, grasp, and manipulate small objects while stabilizing the rope. To further challenge cognitive
engagement and sequencing, the task was upgraded by incorporating letter-number sequences (e.g., “A,3” or
“1,7,H”), requiring the client to retrieve multiple items in order. The client required moderate verbal cues to
maintain attention and complete the sequencing accurately, indicating difficulties with sustained attention
and cognitive flexibility when multi-step instructions were introduced.
During toileting, the client required moderate tactile and verbal cues to properly grasp and pull up her pants
using a functional grasp, placing the thumb inside the waistband and the other fingers to grasp the outside of
the waistband, ensuring the use of her thumbs for efficiency. She needed additional support to remain
 focused on each step before transitioning to the next, such as flushing the toilet before wiping. The client
momentarily became distracted between steps but responded to structured verbal guidance. This suggests
difficulties with task sequencing and sustained attention, which impact her ability to complete multi-step
self-care routines independently. After receiving initial cues, she was able to complete the remainder of the
toileting routine independently, demonstrating emerging skill acquisition but continued need for structured
support.
The next activity the client was in prone position to promote core strength, bilateral coordination, and
sustained attention. The client lay prone in front of the rope from the previous activity and retrieved numbers
as directed, placing them in the correct order. This task required motor planning, sequencing, and sustained
engagement. The client demonstrated motivation to complete the task but required increased verbal and
visual cueing to remain engaged and follow the sequencing correctly. Initially, she attempted to use only her
dominant hand and required moderate assistance to incorporate both hands, suggesting difficulty with
bilateral coordination and task execution. Minimal tactile cueing was needed to facilitate postural alignment
and prevent excessive weight-shifting, indicating mild challenges with postural stability and endurance in
prone positioning.
A dressing-focused obstacle course was incorporated to address lower-body dressing skills within a
structured, engaging format, while integrating Mardi Gras-themed elements for increased motivation. The
obstacle course consisted of gross motor tasks targeting balance, coordination, and sequencing, with a
functional adaptation replacing sock and shoe donning with placing Mardi Gras-colored ponytail holders
around the ankles. The course included: Stepping over balance beams in a zigzag pattern to promote weight
shifting, coordination, and controlled foot placement. Crawling through a tunnel to engage upper body
strength, spatial awareness, and postural control while transitioning between movement-based tasks. Sitting
on a small stool to place stretchy ponytail holders around her ankles, mimicking the motion of donning
socks. The client was instructed to grab a colored ponytail holder, stretch it with both hands, and move it
over her foot and ankle, supporting bilateral hand use, hand strengthening, and motor planning. She placed
four total ponytail holders (two per ankle) before progressing. Jumping between steppingstones, targeting
dynamic balance, coordination, and visual-motor integration. Throwing Mardi Gras beads into a bucket,
reinforcing hand-eye coordination, force control, and proprioceptive input while providing a celebratory
conclusion to the course.

A: The client demonstrated engagement and motivation throughout the session but required frequent redirection
and assistance to sustain attention and complete tasks. She exhibited difficulty accepting redirection, often
becoming frustrated when making mistakes, requiring structured support to regulate emotions and re-engage.
During the dressing-based obstacle course, the client required moderate assistance to position and secure the
rings around her ankles, indicating continued difficulty with lower-body coordination and proprioception.
She frequently attempted to place the rings using one hand rather than stretching them with both hands,
requiring verbal and tactile cues to encourage bilateral hand use and controlled movements.
Fine motor activities indicated difficulties with spatial awareness, adjusting force appropriately, and
maintaining precision within designated boundaries. The client’s toileting independence improved, but she
continued to require verbal prompting for sequencing.

P: Continue interventions targeting attention, self-regulation, and frustration tolerance by incorporating

structured activities that require continued focus and adaptive coping strategies. Provide increased
opportunities for bilateral coordination through both fine and gross motor activities, ensuring the client
engages in tasks that promote the use of both hands and improve motor planning. Reinforce toileting
independence by applying structured verbal and visual cues to support task sequencing and minimize
distractions. Maintain dressing-based interventions within engaging gross motor plans, allowing the client to
practice lower-body dressing skills, such as orienting and manipulating clothing, in a structured and
motivating environment. Focus on improving motor planning, proprioceptive awareness, and sequencing for
donning and doffing to promote improved independence in dressing tasks.
Conference with Client/Caregiver/Family/Significant Other:
Met with the teacher, who expressed concerns regarding the client’s task sequencing and sustained attention,
particularly when following multi-step directions in structured activities. The client often requires additional
verbal prompting and visual support to complete tasks efficiently. The teacher also noted difficulties with
dressing independence, specifically when putting on socks and shoes, as the client struggles with proper
orientation and fit. Briefly spoke with the client’s mother, who shared similar concerns regarding dressing
independence and emotional regulation. Discussed strategies and interventions planned to support
improvement in these areas, focusing on motor planning, sequencing, and frustration tolerance.