Occupational Therapy Progress Report: December 2001
Stephanie
Byrley,
OTR
Evansville,
IN
47715
Progress
Report
for
Occupational
Therapy
December
2001
Client
Name:
Crystal
Allbritton
Evansville,
IN
47710
Date of Birth: 7-18-99
Parent: Brenda Brames
Physician: Neil Propst, M.D.
Service Coordinator: Terry Rizen
Treatment Order: Occupational therapy one time per week for 45-minute sessions.
Long Term Goal # 1: Crystal will demonstrate function range of motion and strength for play and self care tasks.
Objective
#1:
Crystal
will
demonstrate
160
degrees
of
active
shoulder
flexion
consistently
to
raise
both
arms
above
her
head
during
play
and
self
care.
Progress:
Crystal
demonstrates
approximately
125
degrees
of
active
range
of
motion
during
play
activities
1-2
times
during
therapy
sessions.
Crystal
reaches
overhead
to
put
balls
into
a
container
and
puts
beads
on
over
her
head.
Crystal
has
made
progress
from
last
month
when
she
was
reaching
at
chin
level
only.
Also,
Crystal's
ability
to
weight
bear
has
improved
and
she
is
able
to
tolerate
approximately
30
seconds
to
1
minute
with
head
support
demonstrating
improved
stability/strength
at
the
shoulders.
Objective
#2:
Crystal
will
demonstrate
full
active
range
of
motion
of
all
joints
in
both
of
her
hands
and
wrists.
Progress:
Crystal
demonstrates
full
active
range
of
motion
for
all
joints
of
the
hand
with
the
exception
of
the
ring
finger
on
the
left
hand
and
with
supination.
However,
she
requires
cues
to
fully
extend
and
flex
her
fingers
when
playing
dress
up
games
with
the
baby,
squeezing
and
flattening
play
dough,
and
when
putting
on
jewelry.
There
is
full
passive
range
of
motion
in
the
ring
finger
of
the
left
hand.
Crystal
achieves
approximately
15
degrees
of
supination
with
passive
range
of
motion.
This
is
parallel
to
what
Crystal
was
doing
last
month.
We
will
try
Crystal
with
a
resting
hand
splint
to
keep
the
hand
in
a
functional
position
during
hours
of
rest.
Long Term Goal #2: Crystal will maintain breath support to decrease respiratory illnesses.
Objective
#1:
Crystal
will
activate
a
whistle
2
times
per
therapy
session.
Progress:
Crystal
improved
her
performance
this
month
by
blowing
bubbles
on
two
occasions,
however
this
activity
is
not
consistent
and
she
does
not
activate
whistles.
Objective
#2:
Crystal
sing
along
to
one
verse
of
Itsy
Bitsy
Spider
doing
the
hand
motions
to
demonstrate
increased
aerobic
and
lung
capacity.
Progress:
Crystal
does
not
attempt
to
sing
when
participating
in
musical
games.
Rehabilitation Potential and Prognosis: Good for goals.
Comments: Crystal is alert and cooperative with therapy sessions. She enjoys imaginative play with babies, playing with play dough, coloring/drawing, and playing "basketball." She participated in all planned therapy sessions. Continue with occupational therapy but will discuss at the annual IFSP the option of increasing therapy sessions from 45 minutes to 60 minutes.
Thank
You,
Stephanie
Byrley,
OTR
Occupational
Therapist
Date