| 217 | | Plan Date: 03-10-2026 | | Physical Assessment Summary: Self Care/ADLs:
Current Feeding Method: Primitive grasp noted
Types of Food: Eating variety of food; table foods
Sleep Pattern/Cycle: Sleeping through the night
Dressing/Toileting: Partially participate in dressing
Mobility & Transition:
Locomotion: Crawling and pulling to stand on solid surfaces only ; not cruising along furniture yet
Complicating/Personal Factors Affecting the Plan of Care:
Mechanism of injury/ Illness: Congenital
Multiple Treatment Areas: Decreased body awareness/spacial awareness, Hypotoinia weakness, decreased balance and atypical gait
Patient age: 15 month
Time since onset of injury/illness: Since birth
Medical History Review:
High Complexity: The patient has a history of present problem with a history of 3 or more factors and/or comorbidities that impact the plan of care.
Assessment:
Child assessed using a Standardized Assessment
Clinical Observations: hypotonia throughout, weakness, decreased coordination affecting mobility, limited spacial awareness, decreased balance, atypical gait
Parental Report: wants to see patient walk IND
The patient is a 15-month-old female referred to physical therapy secondary to hypotonia, decreased kinesthetic awareness, impaired spatial awareness, and atypical gait pattern. The patient presents with global gross motor delays characterized by decreased strength, limited mobility, impaired balance, reduced coordination, decreased activity tolerance, decreased focal attention, and diminished kinesthetic sense. These deficits significantly impair the patient’s ability to perform age-appropriate gross motor skills required for developmental milestones, participation in daily routines, and overall functional mobility.
Standardized testing using the Peabody Developmental Motor Scales–Second Edition (PDMS-2) revealed the patient scored at a 10-month age equivalency on the Locomotion subtest, indicating poor performance in both simple and complex gross motor skills. This represents a significant delay compared to chronological age and places the patient at risk for continued developmental limitations without intervention.
Due to hypotonia, impaired motor planning, and decreased postural control, the patient demonstrates difficulty with age-appropriate locomotor skills and environmental interaction. These impairments substantially impact the patient’s ability to explore her environment, participate in play, and progress toward expected developmental milestones.
Skilled physical therapy services are medically necessary to address these impairments through targeted interventions aimed at improving strength, postural stability, coordination, balance, motor planning, and kinesthetic awareness. Therapy will focus on promoting functional mobility, enhancing flexibility and active range of motion, facilitating age-appropriate gross motor development, and minimizing the risk of long-term functional limitations to support the patient in achieving optimal developmental outcomes and participation with peers.
Patient would greatly benefit from skilled PT interventions in order to address established delays and facilitate functional independence and performance. Home programming alone is not sufficient to make the needed progress, direct one to one services are required for progress to be achieved. Results of the evaluation were reported and explained to parent(s), along w/ the diagnosis, prognosis, including the frequency, time and duration of treatment and contents of the plan of care. Family will be provided w/ a verbal report of progress noted along w/ any homework for the family as part of a home program (if applicable) at the end of every session. Parent(s) verbalized understanding of treatment plan and agreed to the initiation of skilled therapy. | | Physical Rehabilitation Potential: Good. with consistent Physical Therapy and parental support | | Physical Treatment Plan: | | Physical Long Term Goals: | | Category | Goal Description | | In 6 months, Patient will demonstrate improved kinesthetic awareness by accurately placing feet on line during supported or independent stepping without crossing midline or excessive widening of base of support in 4 out of 5 trials to promote advance balance | | In 6 months, Patient will initiate, stop, and resume independent walking without external support or loss of balance over 4 out of 5 trials to promote balance and coordination with gait/mobility. | | In 6 months, Patient will ambulate independently across 30 feet with Good balance with one or less loss of balance to promote gait pattern to allow participation in age-appropriate mobility and play within 4 out of 5 trials. |
| | Physical Short Term Goals: | | Category | Goal Description | | In 3 months, Patient will independently transition from floor to standing through half-kneel without assistance to promote strength and motor planning in 3 out of 4 trials to promote transitions . | | In 3 months, patient will take 3 steps independently across 3 out of 4 trials over 1 week period to promote balance, kinesthetic sense and pre gait activity | | In 3 months, Patient will transition from supported standing to unsupported standing and sustain balance during play for 10 seconds without loss of balance in 3 out of 4 trials to promote upright balance and prepare for dynamic mobility and ambulation. | | In 3 months, patient will transition between 2 horizontal surfaces independently, sustaining balance for safe transition across 2out of 4 trials to promote balance for pre gait activity |
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