| 5394 | | Plan Date: 03-20-2026 | | Occupational Assessment Summary: Esther was assessed via: PDMS-2 Standardized Assessment, Clinical Observations and Parental Report
PDMS-2 - Per standardized assessment scores Esther falls well below average in both subsets assed on the PDMS-2 evident by below average age equivalency scores ranging from 28 months to 35 months compared to his chronological age of 55 months, placing him at least (-2 to -3) standard deviations behind his peers.
Esther demonstrates deficits in fine motor precision, fine motor integration, visual motor integration, manual dexterity, manual coordination, sensory processing and primitive reflex integration, which have impaired their ability to complete activities of daily living and instrumental activities of daily living that compromise their routines and roles at home and in the community. Child would greatly benefit from skilled OT interventions in order to address their 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 mother, 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 household and/or pt. as part of a home program (if applicable) at the end of every session. Mother verbalized understanding of treatment plan and agreed to the initiation of skilled therapy. | | Occupational Progress to Date: Initial POC- Baseline 0% | | Occupational Rehabilitation Potential: Good. with consistent Occupational Therapy and parental support | | Occupational Treatment Plan: | | Occupational Long Term Goals: | | Category | Goal Description | | Self Care | In 6 months, Esther will utilize appropriate scooping grasping pattern for 8 minutes during mealtime with MOD assistance in order to increase function al independence during feeding and utensil management, 4/5 trials. Baseline- MAX assist to scoop | | Self Care | In 6 months, Esther will demonstrate functional crossing of midline during self-help tasks (e.g., reaching across to pull up pants, don a shirt, or wipe face) with MOD assist or use of compensatory strategies, to increase bilateral hand u se and independence in ADL participation, 4/5 trials. Baseline- MAX assist to cross midline when participating in functional tasks | | Bilateral Coordination | In 6 months, Esther will demonstrate improved BUE strength by completing a 3 minute gross motor circuit (e.g., bear walks, wall pushups, wheelbarrow walking with support) using both arms with good form and with MOD compensations, in order to participate in age appropriate play and self-care tasks, 4/5 trials. Baseline- MAX compensations due to low tone in BUEs |
| | Occupational Short Term Goals: | | Category | Goal Description | | Self Care | In 3 months, Esther will utilize appropriate scooping grasping pattern for 5-8 minutes during mealtime with MOD assistance in order to increase function al independence during feeding and utensil management, 3/4 trials. Baseline- MAX assist to scoop | | Self Care | In 3 months, Esther will demonstrate functional crossing of midline during self-help tasks (e.g., reaching across to pull up pants, don a shirt, or wipe face) with MOD assist or use of compensatory strategies, to increase bilateral hand u se and independence in ADL participation, 3/4 trials. Baseline- MAX assist to cross midline when participating in functional tasks | | Bilateral Coordination | In 3 months, Esther will demonstrate improved BUE strength by completing a 2-3 minute gross motor circuit (e.g., bear walks, wall pushups, wheelbarrow walking with support) using both arms with good form and with MOD compensations, in order to participate in age appropriate play and self-care tasks, 3/4 trials. Baseline- MAX compensations due to low tone in BUEs |
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