Stephanie
Byrley,
OTR
Evansville,
IN
47715
Progress
Report
for
Occupational
Therapy
January
2002
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
several
times
during
therapy
sessions.
Crystal
reaches
overhead
to
put
balls
into
a
container
and
puts
beads
on
over
her
head.
Crystal's
ability
to
weight
bear
has
remained
consistent
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.
Crystal
is
wearing
a
wrist/hand/finger
orthosis
on
a
trial
basis
to
try
and
correct
the
flexion
contracture
of
her
4th
digit
on
the
left
hand.
If
Crystal
tolerates
this
orthotic,
we
will
request
funding
for
bilateral
hand
splints
to
reduce
the
risk
of
soft
tissue
contractures.
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
blows
bubbles
on
during
to
therapy
sessions,
however
this
activity
is
not
consistent
and
she
does
not
activate
whistles.
Crystal
has
not
had
as
much
coughing
with
secretions
during
the
last
two
months
possibly
related
to
a
new
supplement
she
is
trying.
Crystal
does
not
tolerate
the
breathing
exercise
of
light
holding
to
her
rib
cage
during
expiration.
Objective
#2:
Crystal
will
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: Therapy sessions have increased from 45 minute sessions to 60 minute sessions. Crystal tolerates the extra 15 minutes and is making good progress. This month Crystal moved into an apartment with her Mom and siblings. She is adjusting well and has a lot of toys to keep her active and learning.
Thank
You,
Stephanie
Byrley,
OTR
Occupational
Therapist
Date
