| 5282 | | Plan Date: 02-12-2026 | | Occupational Assessment Summary: Gideon was assessed via: PDMS-2 Standardized Assessment, Clinical Observations and Parental Report
PDMS-2 - Per standardized assessment scores Gideon falls below average in 2 subtests assed on the PDMS-2 evident by below average age equivalency scores ranging from 1 month to 2 months compared to his chronological age of 2 months and 18 days, placing him at least (-2) standard deviations behind his peers. Primitive reflexes acting and appropriate for developmental age, to continue monitoring integration and presence of all reflexes, palmar grasping diminished ~ 3 MMT and and UB strength at ~3 MMT- ROM of neck, shoulders and BUEs at ~10 degree limitation; limitations to neck rotation noted, more specifically L rotation and lateralization with stiffness noted on R side, possible cranial asymmetry ~2-3 degrees from left frontal quadrant to R posterior cranial quadrant, to increase ROM and stretching via myofascia release and manual therapy.
Gideon demonstrates deficits in visual motor integration, manual dexterity, ROM, UB strength, low tone , which have impaired his ability to complete activities of daily living and instrumental activities of daily living that compromise his 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 parents, 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. Parents 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 | | Bilateral Coordination | In 6 months, Gideon will demo spontaneous crossing of midline during self help tasks, with MOD assist, to increase bilateral use of hands and ADL participation, 4/5 trials. Baseline- MAX assist | | Motor Planning/Praxis | In 6 months, Gideon will demo hand-to-mouth movements for 3 minutes with BUEs during feeding task, with MOD assist, to increase eye-hand coordination and self-care participation, 4/5 trials. Baseline- MAX | | Balance | In 6 months, Gideon will push up onto forearms and hold the position for 20 seconds during tummy time with MOD tactile cues, to increase shoulder stability and core strength, 4/5 sessions. Baseline- MAX tactile cues |
| | Occupational Short Term Goals: | | Category | Goal Description | | Bilateral Coordination | In 3 months, Gideon will demo spontaneous crossing of midline during self help tasks, with MOD assist, to increase bilateral use of hands and ADL participation, 3/4 trials. Baseline- MAX assist | | Motor Planning/Praxis | In 3 months, Gideon will demo hand-to-mouth movements for 3 minutes with BUEs during feeding task, with MOD assist, to increase eye-hand coordination and self-care participation, 3/4 trials. Baseline- MAX | | Balance | In 3 months, Gideon will push up onto forearms and hold the position for 1 0-20 seconds during tummy time with MOD tactile cues, to increase shoulder stability and core strength, 3/4 sessions. Baseline- MAX tactile cues |
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