The Hashemite University
Faculty of Allied Health Sciences
Occupational Therapy Department
Pediatric Care Plane
Demographic Data and Referral to OT Services
Pt. Name (First, and Last) DOB
Current diagnosis:
Surgical history (specify):
Heart battery
Gender __________________ height ____________________ weight _______________
Referred to Occupational Therapy by:
Date of the referral:
1
Assessments:
□ Activities of Daily Living (ADL)
□ Instrumental Activities of Daily Living (IADL)
□ Social Participation
□ Play Occupation
□ Academic functions
□ Mental Functions
□ Sensory Functions and Pain
□ Neuromuscular and Movement-Related Functions
o Joint Mobility (ROM)
o Joint Stability
o Posture (symmetry and alignment)
o Muscle power/strength
o Muscle tone
o Muscle endurance
o Primitive reflexes
o Automatic movement reactions
o Control of voluntary movements
o Fine motor control
o Gross motor control
o Transitional Movements
o Occulomotor control
o Gait Patterns
Standardized Tests:
□ Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III)
□ Childhood Autism Rating Scale, Second Edition (CARS2)
□ Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA-Ch)
□ School Function Assessment (SFA)
□ Pediatric Evaluation of Disability Inventory (PEDI)
□ TVPS
□ TVMS
□ PDMS
□ Bruininks Oserietsky test
2
Evaluation Results
1. Occupational Profile:
2. Analysis of Occupational Performance and the Underlying Problems
3
3. Intervention Approach (what is the rational for using each of the following approaches):
□ CREATE/PROMOTE (e.g., health promotion)
□ ESTABLISH/RESTORE (e.g., skill acquisition or remediation)
□ MODIFY/ADAPT (e.g., environmental modification)
□ PREVENT (e.g., early intervening support; avoid secondary complications)
Intervention
1- Intervention Plan (long-term and short-term goals)
2- FRAMES OF REFERENCE/PRACTICE MODELS (what is the rational for using each
of the following approaches):
4
□ Occupational – based on the understanding that participation is a dynamic
interaction between student, environment, and activity, which are inseparable parts
of one whole performance event in time and place
□ Behavioral - focuses on the acquisition and learning of specific skills in all areas of
development
□ Biomechanical - used when a person has neuromuscular or musculoskeletal
dysfunction and cannot maintain appropriate muscle activity or posture. Adaptive
equipment is used to help compensate for the lack of function so that students can
perform functional skills as efficiently as possible
□ Cognitive - uses cognitive theory to support the development of functional skills
within the student's environment
□ Coping - based on a cognitive-behavioral model; Through the development and
utilization of coping resources, the student is able to deal with current challenges
and to develop a repertoire of skills needed to address future challenges
□ Developmental - based on an understanding of normal development that recognizes
both the sequential nature of development and the fact that there are basic
foundations from which skills develop
□ Motor control - emphasizes the therapeutic use of functional tasks as well as
provision of feedback to the learner to support the development of motor skills
needed to participate in daily life activities
□ Neurodevelopmental - sensorimotor approach in which techniques are applied to
help facilitate normal developmental patterns; interventions are designed to help
enhance the quality of movement and motor performance within the environment
□ Sensory integration - based on the understanding that the organization of sensory
information in the brain may help children develop adaptive responses to
successfully meet environmental challenges
Choose the practice model/s suitable for the child and write here the rationale why you
made this choice:
5
Type of intervention used:
□ ONE-ON-ONE INTERACTION
□ GROUP
□ CONSULTATION WITH TEAM MEMBERS (e.g., problem solving)
□ EDUCATION OF TEAM MEMBERS (e.g., training)
□ ENVIRONMENTAL ADAPTATION (e.g., assistive technology)
Outcomes:
6
Progress Notes
Date Progress
Discharge Note:
7
Home Program:
8
I. Evaluation of Areas of Occupation
A. Evaluation of Activities of Daily Living (ADLs)
Level of functioning:
- Independent: Ind.
- Needs verbal assistance: V/A
- Needs physical assistance: Ph/A
- Dependent: Dep.
- Not Applicable: N/A
Area of functioning Level of functioning
Ind. V/A Ph/A Dep. N/A Notes
1. Feeding
- Take cereal or
pureed food
from spoon
- Attempt to hold
bottle and may
retrieve it if it
falls
- Hold and try to
eat cracker
- Finger-feed self
- Dip spoon in
food
- Bring spoonful
of food to
mouth
- Scoop food
from the plate
- Orient the
spoon to mouth
properly
- Keep and
manipulate
food or fluid in
the mouth and
swallow it
2. Dressing
- Select
appropriate
clothing
- Obtain clothing
from storage
area
9
Area of Ind. V/A Ph/A Dep. N/A Notes
function
- Undress in a
sequential
fashion
- Dress up in a
sequential
fashion
- Fasten and
adjust clothing
and shoes
- Untie shoes
- Tie shoes
- Apply and
remove
personal
devices,
prosthesis, or
orthosis
3. Bathing and
showering
- Obtain and use
supplies
- Soaping
- Rinsing
- Dry body parts
- Maintain
bathing position
- Transfer to and
from bathing
position
4. Bowel and
bladder
management
5. Toilet hygiene
- Obtain and use
supplies
- Manage
clothing
- Maintain
toileting
position
- Transfer to and
from toileting
position
- Clean body
10
- Care for
continence
needs
Area of Ind. V/A Ph/A Dep. N/A Notes
function
6. Personal
hygiene and
grooming
- Obtain and use
supplies
- Wash face and
hands
- Dry body
- Comb hair
- Brush teeth and
clean mouth
- Care for skin,
ears, nose, and
eyes
7. Functional
mobility
- In-bed mobility
- Wheelchair
mobility
- Transfer from
wheelchair to
bed
- Transfer from
wheelchair to
tub
- Transfer from
wheelchair to
toilet
- Transfer from
wheelchair to
chair
- Transfer from
wheelchair to
floor
- Functional
ambulation and
transporting
objects
Comments:
11
B. Evaluation of Instrumental Activities of Daily Living (IADLs)
Level of functioning:
- Independent: Ind.
- Needs verbal assistance: V/A
- Needs physical assistance: Ph/A
- Dependent: Dep.
- Not Applicable: N/A
Area of Function Level of functioning
Ind. V/A Ph/A Dep. N/A Notes
1. Communication
management
- Able to send effective
verbal message
- Able to send nonverbal
message
- Show appropriate
listening
- Give full attention to the
speaker
- Aware to the speaker’s
nonverbal messages
- pay attention to the
speaker’s words and
feelings
- communicate in a socially
appropriate way
2. Community mobility
3. Safety and emergency
maintenance
4. Meal preparation and
cleanup
5. Health management and
maintenance
6. Religious observance
7. Shopping
- Preparing shopping list
- Selecting
- Purchasing
- Transporting items
- Selecting method of
payment
- Completing money
transaction
Comments:
12
C. Evaluation of Social Participation
- Always: more than 75% of the time
- Often: 50-75% of the time
- Sometimes: 25-50% of the time
- Rarely: Less than 25% of the time
Social Participation Level
Always Often Sometimes Rarely Notes
Socialize with family
and friends
Communicate needs,
wants, and interests
effectively
Find it hard to make
friends among age-
related peers
Prefer to stay home
rather than going with
the group
Join in school or
community activities
Seek out friends and
companions
Need or desire a
companion or caregiver
in close contact during
the day or at night
Comments:
13
D. Evaluation of Play Occupation
- Always: more than 75 of the time
- Often: 50- 75% of the time
- Sometimes: 25-50% of the time
- Rarely: Less than 25% of the time
Play Behavior and Level
development Always Often Sometimes Rarely Notes
Exploratory play (0-1
yrs)
Social Play (0-up)
Solitary (0-2 yrs)
Functional Play
(6months-up)
Symbolic play (2-4 yrs)
Parallel (2.5-3 yrs)
Creative play (4-6 yrs)
Games with rules ( 7-12
yrs)
Tend to play or interact
with others that are
younger or require care
giving
Have fun with other
children in the
neighborhood, at school,
or other social situations
Enjoy toys or games that
are developmentally
appropriate
Enjoy time alone
entertained by hobbies
and interests
Comments:
14
E. Evaluation of Academic functions
Academic Function Level of functioning
Age Able Delayed Unable N/A Notes
appropri With
ate assistan
ce
1. Recognize familiar
objects
2. Recognize colors
3. Recognize shapes
4. Color inside shapes
5. Crayon/ pencil grip
6. Hold paper while
coloring/writing
7. Hand preference
8. Name shapes
9. Draw a person
10. Name letters
11. Name numbers
12. Write name
13. Use scissors to cut
- Snip
- Cut
- Cut on a line
- Cut circle
- Cut square
- Cut Simple shapes
- Cut Complex shapes
14. Crayon/marker use
- Scribble
- Trace shapes
- Imitate horizontal,
vertical, circle
- Copy vertical line,
horizontal line, and
circle
- Copy cross, oblique
line, square
- Copy some letters and
numerals
- Copy triangle
- Handwriting
appropriate for age
Comments:
15
II. Evaluation of Body Functions
A. Evaluation of Mental Functions
Mental function Level of functioning
Able Needs Not N/A Notes
prompting able
1. Higher-level cognitive
- Judgment
- Concept formation
- Insight
- Attention
- Awareness
2. Attention
- Sustained
- Selective
- Divided attention
3. Memory
- Short-term
- Long-term
- Working memory
4. Perception
- Discrimination of
sensations including:
- Auditory
- Tactile
Steriognosis
Graphesthesia
Body scheme
- Visual and visual spatial
Agnosia
Figure-ground
Form constancy
Position in space
Right-left discrimination
Depth Perception
Topographical orientation
- Olfactory
- Gustatory
- Vestibular
- Proprioception
- Multi-sensory processing
5. Thought
- Recognition
- Categorization
- Generalization
- Awareness of reality
16
- Logical/coherent thought
- Appropriate thought
content
Mental function Able Need Not N/A Notes
prompt able
6. Mental functions of
sequencing complex
movement
- Execution of learned
movement patterns
7. Emotional
- Coping
- Behavioral Regulation
8. Experience of Self and
time
- Body image
- Self-concept
- Self-esteem
Results of Standardized tests:
Comments:
17
B. Evaluation of Sensory Functions and Pain:
Sensory function Level
Intact Affected N/A Notes
1. Seeing & related
functions
- Visual acuity
- Visual Stability
- Visual field function
- Detection/registration
- Modulation
- Integration of sensations
from the body and
environment
- Visual awareness of
environment at various
distances
2. Hearing function
- Tolerance of ambient
sounds
- Awareness of location and
distances of sounds
3. Vestibular functions
- Sensation of securely
moving against gravity
4. Taste functions
5. Smell functions
6. Proprioceptive
functions: Awareness of
body position in space
7. Touch functions:
(comfort with being touch
or touching different
textures)
8. Pain
- Diffuse
- Dull
- Sharp
- Phantom
9. Temperature and
pressure
Results of Standardized tests:
Comments:
18
C. Evaluation of Neuromuscular and Movement-Related Functions
Neuromuscular and
Movement-Related Present Not present Description
Functions
1. Joint Mobility
(ROM)
- Limitations in
upper extremity
joints
- Limitations in
lower extremity
joints
- Limitations for
bone or soft
tissue
contractures
- Asymmetries
2. Joint Stability
3. Posture
(symmetry and
alignment)
- Supine
- Prone
- Sit
- Stand
- Prone extension
- Supine flexion
4. Muscle
power/strength
5. Muscle tone
- At rest
- During
movement
- Hypotonicity
- Hypertonicity
- Fluctuating tone
- Abnormal tone in
extremities
- Abnormal tone in
trunk
19
- Exaggerated
stretch reflex
(clonus)
- Asymmetries
Neuromuscular Present Not present Description
and movement-
related function
6. Muscle
endurance
7. Primitive
reflexes
- Asymmetric
tonic neck reflex
- Symmetric tonic
neck reflex
- Tonic
Labyrinthine
reflex (prone)
- Tonic
Labyrinthine
reflex (supine)
- Walking reflex
- Neonatal positive
support reflex in
standing
- Grasp reflex
- Planter reflex
8. Automatic
movement
reactions
- Righting
reactions
Neck on body
Body on body
Body on head
Landue
Flexion
Vertical
- Equilibrium
reactions
Prone
Supine
Sitting
Quadruped
Standing
20
- Protective
reactions
Forward
Lateral
Backward
Neuromuscular Present Not Description
and movement- present
related function
9. Control of
voluntary
movements
- Eye-hand/foot
coordination
- Bilateral
integration
- Crossing midline
10. Fine motor
control
- Bilateral reach
- Unilateral reach
- Whole hand
grasp
- Partial hand
grasp
- Digital grasp
- Tripod grasp
- Pincer grasp
- Support hand on
surface to release
object
- Well controlled
release
- Release tiny
objects into small
container
- Throw ball with
accuracy
- Transfer objects
between hands
- Manipulate
objects within the
hand
Finger to palm
Palm to finger
Shift
21
Simple rotation
Complex rotation
Translation with
stabilization
- Hand preference
Neuromuscular Present Not Description
and movement- present
related function
11. Gross motor
control
- Sit with support
- Sit without
support
- Pivot in prone
(coordinated use
of all four
extremities)
- Crawl on
stomach
- Creep on all four
- Stand with
support
- Stand without
support
- Cruise along
furniture
- Walk with
support
- Walk without
support
- Ascend stairs
with support
- Ascend stairs
without support
- Descend stairs
with support
- Descend stairs
without support
- Jump in place
with both feet
22
- Jump forward
with both feet
- Run
- Hop
- Skip
Neuromuscular Present Not Description
and movement- present
related function
12. Transitional
Movements
- Rolling with
rotation (prone to
supine
- Rolling with
rotation (supine
to prone)
- Sit to prone with
rotation
- Prone to sit with
rotation
- Supine to sit with
rotation
- Pull to stand
from half-kneel
- Stand to sit with
control
13. Oculomotor
control
14. Gait Patterns
Results of Standardized tests:
Comments:
23
