| 5305 | | Plan Date: 02-20-2026 | | Occupational Assessment Summary: Maisie is a 7-year, 6-month-old female who presents for an occupational therapy evaluation to determine her current functional abilities. Based on clinical observation, caregiver interview, and informal assessment, Maisie demonstrates significant deficits across multiple developmental domains, including sensory processing, emotional regulation, and activities of daily living, which impede her ability to participate in age-appropriate occupations at home and in school. The reliability of this assessment is considered questionable due to the patient's distractibility, delayed response rate, and need for numerous prompts to ensure cooperation. However, the observable functional limitations provide clear evidence of developmental delays. The patient's prognosis for making gains with therapeutic intervention is good. Functionally, Maisie presents with significant deficits in sensory processing and modulation, with performance estimated to be more than six months below age expectations. She exhibits hyper-responsivity to both auditory and tactile stimuli, which negatively impacts her attention to task in stimulating environments and her tolerance for essential self-care routines like grooming. These sensory challenges directly contribute to poor self-regulation, which manifests as low frustration tolerance, poor impulse control, and frequent behavioral outbursts that are inconsistent with her age. These regulatory deficits, which are substantially greater than a six-month delay, interfere with her capacity to engage in cooperative play, follow multi-step directions, and safely navigate social interactions. These underlying sensory and regulatory challenges directly impact her independence in Activities of Daily Living (ADLs). Maisie requires assistance with fundamental self-care tasks, including washing and drying her hands, opening meal containers, and managing clothing fasteners for dressing and toileting. Deficits in fine motor dexterity, bilateral coordination, and motor planning are evident. Given that mastery of these skills is expected between 4 and 6 years of age, her current performance reflects a significant functional delay of approximately 18-36 months, placing her well below the 50th percentile when compared to same-aged peers. This reliance on adult support for basic personal care undermines her functional autonomy and limits her participation in daily routines. In summary, Maisie presents with significant, measurable deficits in sensory modulation, emotional regulation, and fine and gross motor coordination that result in substantial limitations in self-care independence, social participation, and the ability to engage in academic tasks. The convergence of these deficits creates a clear risk for widening developmental gaps and increasing dependence on caregivers. Therefore, skilled occupational therapy services are medically necessary to address these identified deficits, improve underlying skills, and enhance functional performance in daily occupations. Due to the severity of her delays, the pervasive impact on her functional independence across multiple settings, and safety concerns related to poor impulse control and emotional dysregulation, it is recommended that Maisie receive skilled occupational therapy services two (2) times per week. This frequency is required to provide sufficient intensity to remediate foundational skill deficits, establish adaptive coping strategies, and prevent further regression or the development of maladaptive behaviors. Postponement of intervention would place the patient at high risk for continued functional decline and would compromise her ability to achieve age-appropriate independence.
| | Occupational Rehabilitation Potential: Good. with consistent Occupational Therapy and parental support | | Occupational Treatment Plan: Maisie is a 7-year, 6-month-old female who presents for an occupational therapy evaluation to determine her current functional abilities. Based on clinical observation, caregiver interview, and informal assessment, Maisie demonstrates significant deficits across multiple developmental domains, including sensory processing, emotional regulation, and activities of daily living, which impede her ability to participate in age-appropriate occupations at home and in school. The reliability of this assessment is considered questionable due to the patient's distractibility, delayed response rate, and need for numerous prompts to ensure cooperation. However, the observable functional limitations provide clear evidence of developmental delays. The patient's prognosis for making gains with therapeutic intervention is good. Functionally, Maisie presents with significant deficits in sensory processing and modulation, with performance estimated to be more than six months below age expectations. She exhibits hyper-responsivity to both auditory and tactile stimuli, which negatively impacts her attention to task in stimulating environments and her tolerance for essential self-care routines like grooming. These sensory challenges directly contribute to poor self-regulation, which manifests as low frustration tolerance, poor impulse control, and frequent behavioral outbursts that are inconsistent with her age. These regulatory deficits, which are substantially greater than a six-month delay, interfere with her capacity to engage in cooperative play, follow multi-step directions, and safely navigate social interactions. These underlying sensory and regulatory challenges directly impact her independence in Activities of Daily Living (ADLs). Maisie requires assistance with fundamental self-care tasks, including washing and drying her hands, opening meal containers, and managing clothing fasteners for dressing and toileting. Deficits in fine motor dexterity, bilateral coordination, and motor planning are evident. Given that mastery of these skills is expected between 4 and 6 years of age, her current performance reflects a significant functional delay of approximately 18-36 months, placing her well below the 50th percentile when compared to same-aged peers. This reliance on adult support for basic personal care undermines her functional autonomy and limits her participation in daily routines. In summary, Maisie presents with significant, measurable deficits in sensory modulation, emotional regulation, and fine and gross motor coordination that result in substantial limitations in self-care independence, social participation, and the ability to engage in academic tasks. The convergence of these deficits creates a clear risk for widening developmental gaps and increasing dependence on caregivers. Therefore, skilled occupational therapy services are medically necessary to address these identified deficits, improve underlying skills, and enhance functional performance in daily occupations. Due to the severity of her delays, the pervasive impact on her functional independence across multiple settings, and safety concerns related to poor impulse control and emotional dysregulation, it is recommended that Maisie receive skilled occupational therapy services two (2) times per week. This frequency is required to provide sufficient intensity to remediate foundational skill deficits, establish adaptive coping strategies, and prevent further regression or the development of maladaptive behaviors. Postponement of intervention would place the patient at high risk for continued functional decline and would compromise her ability to achieve age-appropriate independence.
| | Occupational Long Term Goals: | | Category | Goal Description | | Self Care | Within 6 months, Maisie will independently complete a thorough handwashing routine by performing all 6 steps (turn on water, wet hands, apply soap, scrub all surfaces for at least 20 seconds, rinse, and dry hands) with no more than one verbal prompt in 4 out of 5 opportunities. Currently Maisie is requiring moderate support to wash hands thoroughly. | | Self Care | Within 6 months, Maisie will independently initiate the dressing routine within 2 minutes of a verbal prompt, demonstrating cooperative behavior and task engagement, in 4 out of 5 opportunities to increase independence with self-care skills. Currently Maisie is requiring maximum support to initiate dressing routine and to complete it. | | Fine Motor | Within 6 months, Maisie will write her first and last name completely and legibly, using appropriate letter formation, size, and spacing, in 4 out of 5 opportunities, to improve identification and safety within her environment. Currently Maisie is requiring modeling and moderate verbal prompts to write her first and last name. | | Sensory Issues/Self Regulation | Within 6 months, Maisie will identify her current emotion and independently select and use an appropriate coping strategy (e.g., deep breathing, asking for help, taking a break) to increase ability to self-regulate, with no more than 2 verbal prompts, in 4 out of 5 opportunities. Currently Maisie becomes very upset which will lead into meltdown with inability to regulate. | | Home Management Intervention Program | Within 6 months, the child and caregiver will demonstrate consistent participation in the prescribed home exercise program by completing activities with the caregiver reporting improved carryover of targeted skills during daily routines, in 4 out of 5 weeks. |
| | Occupational Short Term Goals: | | Category | Goal Description | | Self Care | Within 3 months, Maisie will complete a thorough handwashing routine by performing all 6 steps (turn on water, wet hands, apply soap, scrub all surfaces for at least 20 seconds, rinse, and dry hands) with no more than minimal verbal prompts in 3 out of 5 opportunities. Currently Maisie is requiring moderate support to wash hands thoroughly. | | Self Care | Within 3 months, Maisie will initiate the dressing routine within 2 minutes of a verbal prompt, demonstrating cooperative behavior and task engagement, with minimal support in 3 out of 5 opportunities to increase independence with self-care skills. Currently Maisie is requiring maximum support to initiate dressing routine and to complete it. | | Fine Motor | Within 3 months, Maisie will write her first and last name completely and legibly, using appropriate letter formation, size, and spacing, in 3 out of 5 opportunities, with minimal support to improve identification and safety within her environment. Currently Maisie is requiring modeling and moderate verbal prompts to write her first and last name. | | Sensory Issues/Self Regulation | Within 3 months, Maisie will identify her current emotion and select and use an appropriate coping strategy (e.g., deep breathing, asking for help, taking a break) to increase ability to self-regulate, with no more than moderate support, in 3 out of 5 opportunities. Currently Maisie becomes very upset which will lead into meltdown with inability to regulate. |
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