Occupational Therapy Progress Note

Client Name: Dr. T

Session (please identify): ____ Group __X__ Individual
Date of Service: 9/14/23
Number of Participants: 2 (OT and ct.)
OTPF focus for the group: (if focused on client factors or performance skills, also indicate the potential influence on
occupational performance): ADLs – self feeding; modifying
Goal(s) of Session: (include: behavioral statement, criteria, condition and time frame)

(we will cover the format for goal writing later in this class; until that point, just focus on a goal
e.g. “Dr. T. will feed himself a full meal using an adaptive fork without assistance”).

“Dr. T will be modified independent to feed himself a meal of soft foods with an adaptive fork without
spilling, while seated in manual w/c, at least 80% of the time.”

Subjective information: (include direct comments appropriate to session and general subjective impressions;
subjective information includes content related to the client’s occupational profile)

Ct. stated need for lower manual w/c armrests for elbow support during self-feeding. He appeared
calm throughout session. He grimaced, stated that using typical fork was difficult. Noted when
strategies were unsuccessful (“that won’t work”). Ct. agreed that adaptive fork was more effective.

Objective Observations: (include: length, setting and purpose of treatment session; number of participants, type of
services delivered – what skilled intervention was provided & results of services)

Ct. participated in a 5-minute self-feeding session in SNF cafeteria, while seated in manual w/c. Limited
BUE AROM, strength, and grasp currently impacting functional tool use and ability to bring hand to
mouth during ADLs such as feeding. Ct. displayed difficulty with repositioning R grasp on standard fork.
With non-adaptive fork, client required multiple attempts to spear soft foods, dropped fork 1x, and
required multiple attempts to reposition grasp on fork; took 3 attempts to get food to mouth. He
dropped and grasped fork to reposition his grasp due to limited R thumb mobility. Client leaned trunk
forward and opened mouth wider to attempt to bring mouth closer to fork given limited R
elbow/shoulder AROM. Associated LUE movements noted. Client was more successful in bringing food
to mouth given verbal and manual cuing from OT to support elbow on armrest. Trialed thick-handled,
angled fork; Dr. T was able to spear food and bring to mouth more quickly and smoothly using
modified fork on 3/3 attempts, did not req manual cuing to elbow.

Assessment: (identify if goal was met, partially met or unmet; problems, progress & potential; identify additional needs
of client(s) and justify continued need for service. *no new information in this section!*)

Rev. 2.11.23
“Decreased hand strength, limited functional/sustained grasp due to dec. thumb mobility, limited neck
AROM, and limited anti-gravity BUE AROM limit client’s ability to independently scoop or spear food
and bring food to mouth during self-feeding. Improvement noted in ability to spear soft foods and bring
to mouth given a thick-handled, angled fork. Client made progress towards goal of modified
independent self-feeding, as he was modified independent to spear and eat fruit >50% of the time
today, given adaptive fork and extra time. Commented [LP1]: See if you can ID the contributing
factors, impacts and ability to engage in occupation in this
section!
He would benefit from further adjustments in seating to identify a more appropriate height to rest his R
elbow for support while bringing food to mouth, given limited BUE AROM, as well as repositioning of
preferred food closer to R side to enable easier spearing. Client shows insights about his condition and What about the “3 Ps-“ Problems, Progress and Potential?

problem-solving skills; this suggests good outlook for adaptation to modified equipment and strategies Commented [LP2]: Justifying need for continued service -
he still has OT needs!
to enable more successful participation in ADLs.”

Plan: (include: frequency, duration and purpose of continued therapy; must relate to the assessment of client’s needs;
what changes are planned for the next session)

Continue OT 1x/day until discharge to address BUE AROM, strengthening, positioning, and adaptive
equipment/techniques as needed to enable independence in ADLs. Plan to trial rocker knife and thick-
handled, angled spoon at next session to facilitate more independent self-feeding. Commented [LP3]: We did not dive too deep into the “P”
section during class, but note the frequency, duration and
purpose of therapy; the purpose should ultimately always
point to the occupation!
______Lesley Paige, OTR/L______________________________
You may also include a more specific plan for your next
Therapist’s name (print) session; this will help guide other OTPs to understand your
plan if someone else takes over for you.

______ Lesley Paige _____________________________

Therapist’s signature

Rev. 2.11.23