Occupational Therapy Progress Report: December 2001

Stephanie Byrley, OTR
Evansville, IN 47715

Progress Report for Occupational Therapy
December 2001

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 45-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 demonstrates approximately 125 degrees of active range of motion during play activities 1-2 times during therapy sessions. Crystal reaches overhead to put balls into a container and puts beads on over her head. Crystal has made progress from last month when she was reaching at chin level only. Also, Crystal's ability to weight bear has improved and she is able to tolerate approximately 30 seconds to 1 minute with head support demonstrating improved stability/strength at the shoulders.

Objective #2: Crystal will demonstrate full active range of motion of all joints in both of her hands and wrists.
Progress: Crystal demonstrates full active range of motion for all joints of the hand with the exception of the ring finger on the left hand and with supination. However, she requires cues to fully extend and flex her fingers when playing dress up games with the baby, squeezing and flattening play dough, and when putting on jewelry. There is full passive range of motion in the ring finger of the left hand. Crystal achieves approximately 15 degrees of supination with passive range of motion. This is parallel to what Crystal was doing last month. We will try Crystal with a resting hand splint to keep the hand in a functional position during hours of rest.

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 improved her performance this month by blowing bubbles on two occasions, however this activity is not consistent and she does not activate whistles.

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: Crystal is alert and cooperative with therapy sessions. She enjoys imaginative play with babies, playing with play dough, coloring/drawing, and playing "basketball." She participated in all planned therapy sessions. Continue with occupational therapy but will discuss at the annual IFSP the option of increasing therapy sessions from 45 minutes to 60 minutes.

Thank You,

Stephanie Byrley, OTR 
Occupational Therapist Date

Back Home Directory

Hit Counter