Stephanie
Byrley,
OTR
Evansville,
IN
47715
Progress
Report
for
Occupational
Therapy
February
2002
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 60-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
participates
in
activities
to
increase
active
shoulder
strength
and
stability
to
improve
active
shoulder
flexion.
Activities
include
weight
bearing
on
elbows
with
head
support
and
putting
on
necklaces,
combing
her
hair,
and
putting
objects
into
raised
containers.
Crystal
demonstrates
approximately
130
degrees
of
active
shoulder
flexion
during
most
therapy
sessions.
She
can
maintain
this
position
for
approximately
30
seconds.
Objective
#2:
Crystal
will
demonstrate
full
active
range
of
motion
of
all
joints
in
both
of
her
hands
and
wrists.
Progress:
Crystal
has
been
trailed
with
a
wrist/hand/finger
orthosis
for
the
last
month
and
a
half.
Her
contracture
in
the
left
hand
has
been
corrected.
Recommend
continuing
with
orthotic
wear
to
prevent
further
contractures
in
both
wrists/hands.
Continues
to
lack
supination
bilaterally.
Spoke
with
mom
regarding
splinting
for
the
defecit,
however
this
defecit
has
not
affected
Crystal's
function
so
we
will
not
try
anything
beyond
the
stretches
we
are
already
doing.
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
blows
bubbles
and
activates
a
whistle
one
time
during
the
last
month.
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:
Therapy
sessions
are
one
time
per
week
for
60
minutes.
Crystal
tolerates
the
sessions
well.
We
will
be
having
a
team
conference
at
the
beginning
of
March
to
discuss
Crystal's
transition
to
the
school
corporation.
Thank
You,
Stephanie
Byrley,
OTR
Occupational
Therapist
Date