'OHANA OT EVALUATION pg 1/4
1139 N Princeton Suite B, Wenatchee WA 98801 Ph 509-888-7435 Fax 509-888-7674 ohanaot.com
Client Name
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First Name
Last Name
DOB
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Month
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Day
Year
Date Picker Icon
Age/Grade
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PCP
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Dr. Swidler
Dr. Kawali
Dr. Eisert
Dr. Lindberg
Dr. Hornby
Dr. Crawford
Dr. Baumeister
Dr.Lewis
Dr. Milnes
Dr. Shattuck
Dr. Linn
Dr. Cudney
Other
Medical Diagnosis
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F84.0 Autism
F84.5 Asperger's
F90.9 Unspec ADHD
F90.0 Inatt ADHD
F90.0 Unspec ADHD
F90.2 Combined ADHD
F90.1 Predom Hyper ADHD
F82 Dev Dis motor function
R45.87 Impulsiveness
R46.2 Strange and Inexplicable Behavior
Other
Treatment Diagnosis
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M62.81 Muscle Weakness
F82 Dev Dis motor function (Coord)
G98.8 Unspec Dis NS
R20.2 Parethesia (skin over sens)
Z73.4 Inadequate Social Skills
Other
Was a Pre-Exam history form completed including extensive history (e.g. medical, physical, cognitive, psycho social concerns, , therapy history, occupational profile related to current functional performance)?-
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Yes
No
Date of Evaluation
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Month
-
Day
Year
Date Picker Icon
Date of Onset (DOB if appropriate for Medical Diagnosis, could also be date of regression)):
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Month
-
Day
Year
Date
Red Flags
Appropriate for therapy?
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Yes
No
Maybe
Is there a FUNCTIONAL impairment that interferes with their ability to play/work or self-care?
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Yes
No
Maybe
The Primary Functional Impairment
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Any Secondary Impairments or performance deficits observed by therapist?
Unable to follow warnings or directions
Poor attention
Poor emotional reciprocity
Poor balance
Frequent falls
Unable to sit still
Overly active
Sensory seeking behavior (e.g. crashing body into objects/people)
Delayed play/social skills
Delayed fine motor skills
Delayed gross motor skills
Delayed ocular motor skills
Delayed oral motor skills
Poor ideation/motor planning
Socially inappropriate behaviors to sensory stimuli
Impulsivity
Poor problem solving
Delayed social skills
Other
Additional secondary impairments or performance deficits reported by parent
Sudden outbursts
Tantrums/meltdowns
Verbal aggression
Physical aggression
Insistence on sameness
Ritualized patterns
Rigid thinking patterns
Delayed self care skills
Impulsivity
Other
Since when?
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6 months
Past year
> 1 year
Other
Parent Concern Level
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1/10Mild
2/10 Mild
3/10 Moderate
4/10 Moderate
5/10 Moderate
6/10 Moderate
7/10 Severe
8/10 Severe
9/10 Severe
10/10 Severe
Other
How severe is the condition?
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Mild
Moderate
Severe
Other
Will the condition improve with therapy?
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Yes, very likley
Yes
Somewhat likely
Unlikely
Quick Test & Treatment
Was a Quick Test & Treatment performed?
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Yes
No
PRE-Test Sign
PRE-Test Activity
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Follow direction
1 leg balance
Sit calmly
Other
Range During PRE-Test %
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Page 2/4
Quality of performance during Pre-Test pg 2/4
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Constant fast motion / sensory seeking
Unsteady
Calm / Steady
Lethargic
Shakey
Slow
Weak
Not confident
Other
Pre-Test Level of Independence
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Independant
Self- Assisted
Therapist Assisted
Assistive device used
Other
Test Treatment
What was done?
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Specialized Movement
Specialized Deep Tactile Input
Adapted Visual and Auditory cues
Adapted Tactile cues
Other
Where/How?
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To the affected area
Other
Why was this test treatment chosen?
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Based on the signs and symptomology
Other
Ruled-Out(s)
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Behavior
Cognition
Other
POST-Test Sign
POST-Test Activity
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Same as PRE-Test sign
Other
Range During POST-Test %.
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Quality of Performance during POST-Test
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Less constant motion / sensory seeking
Less unsteady
More calm / steady
Less lethargic
Less shakey
Less weak
Not as slow
More confident
Other
POST-Test Level of Independence
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Independant
Self- Assisted
Therapist Assisted
Assistive device used
Other
Medical Necessity
Is there a possibility the condition will worsen without therapy intervention?
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Absolutley
Yes
Likely
Unlikley
No
Other
Will therapy improve their self -care, social or play skill abilities?
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Yes, very likely
Yes
Unlikely
No
Other
Is there a "Safety Concern"?
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Yes
Not at this time
Impression
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I have a moderate SAFETY CONCERN when this client is performing the activity of playing safely around other children. May accidentally hurt self or others due to poor body awareness, impulsivity and coordination.
Exam Type
Exam Type Performed
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Low Level Exam
Moderate Level Exam
High Level Exam
Quick Screen/ Consult
Quick Exam
Other
Next Step Orders
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Start therapy Program (see "Plan" below)
Schedule for Exam part 2
Refer out to another specialist
Follow up in near future
Other
Finish Exam another day?
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Yes
No
Limiting Factors
Limiting Factors to Success
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Motivation
Prior Level of Function
Support Circle Issues
Comorbid diagnosis
Medication side effects
Has had multiple placements as a foster child
See additional information below
Limiting Factors to Success including significant History
Details on Limiting Factors:
I will address the limiting factors with the patient and find a resolution for each factor. Unless otherwise noted the child is expected to meet my intended functional goals based on my prior level of experience with this type of case or similar case .
Supportive Date
In order to complete the evaluation the therapist provided the significant modification of tasks and/or assistance including the following:
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Visual Modeling
Verbal cuing
Repition of instructions
Intermittent sensory input to increase cooperation/task completion
Physical assist
Tactile cuing
Modification of test items
Change in sequencing of test items
Other
Page 3/4
Performance Deficits causing activity limitations and/or participation restrictions with the functional impairment? pg 3/4
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Weakness/Muscular Dysfunction (core)
Active Primitive Reflexes
Motor Planning/ Ideation Dysfunction
Ocular Motor Dysfunction
Vestibular/movement sense dysfunction (UNDER responsive)
Proprioception/position sense dysfunction (UNDER responsive)
Tactile dysfunction (UNDER responsive)
Visual dysfunction (UNDER responsive)
Auditory dysfunction (UNDER responsive)
Tactile dysfunction (OVER responsive)
Visual dysfunction (OVER responsive)
Auditory dysfunction (OVER responsive)
Vestibular/movement sense dysfunction (OVER responsive)
Tactile dysfunction (fluctuating)
Poor bilateral integration/sequencing
Hypertonicity
Hypotonicity
The above results were obtained from Ayres Clinical Observation Tests
Other
Severity of Dysfunction
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Severe
Moderate
Mild
Basis for this assessment:
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+ Provocation Test(s)
+ Special Test(s)
- Ruled-Out other systems
Other
Additional Testing
Sensory Processing Measure: To be completed next session.
Complexity Level
Evaluation Complexity Level
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Low
Moderate
High
Other
Low Complexity Justification.
Moderate Complexity Justification
High Complexity Justification
Signs and symptoms appear incongruent with the cause of problem, however, they appear consistent with a sensory motor dysfunction. Problem is complicated, unstable, unpredictable, and/or evolving. Several limiting factors also exist. such as comorbid diagnosis, at least 5 performance defecits resulting in activity limitation and or participation restrictions. Significant modifaction or assistance was needed to complete evaluation. See list above.
More notes on Complexity:
Justification for Skilled OT:
There is a significant delay in sensory motor development. In order to develop the following daily task skill goals a skilled OT is required including but not limited to provide visual, verbal, tactile cues, adaptations, physical assist and grading of tasks / activities to the just right level to ensure the client’s success and incremental progress. The goals cannot be met by practicing with a teacher, caregiver or parent with a home program because the skills are not yet developed to the level where they can be merely practiced.
Rehab/ Habilitative Potential
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Excellent
Good
Fair
Poor
Guarded
Other
Plan
Recommendations
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Prescribe Treatment Program (details below)
See once more then home program
Follow-up in 2-4 weeks
Discharge with home and self-care
Refer to Physician
Refer to Developmental/Behavioral Optometrist
Other
Short Term Goal(s): Baseline = Unable (0%). Goals are to 80% (4/5 data days) within 6 months unless otherwise stated. CLIENT WILL.........
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Normalize dysfunctions causing functional impairment in order to achieve primary functional goals.
Participate well with initial home program for 3 weeks for parent /child engagement in therapy program
FOLLOWING DIRECTIONS/FLEXIBLITY/SAFETY
Only put safe items in mouth for safety
Follow a picture schedule for improved following direction and cooperation
Follow safety rules to reduce impulsivity and risk of injury
Wait safely and calmly 5-10 min (fidget ok) to reduce impulsivity and risk of injury
Be flexible with activity choice with no distress/ meltdowns to increase cooperation and ability to participate in age appropriate activities
Add or accept change in play, not rigid to increase cooperation and ability to participate in age appropriate activities
Follow multi-step directions to be able to improve task completion
Follow multi-step peer play with rules to increase cooperation
No longer have a safety concern to decrease dependance on adult supervision
GROSS MOTOR
Have no loss of balance/falls on moving equipment to reduce risk for injury during play
Have no unsafe sensory seeking behavior indoors to reduce risk for injury and increase ability to be in public places
Sit calmly for fine motor activity 15-20 min to increase ability to engage in table top activities.
Ride trike or scooter independently to increase ability to participate in age level skills
Ride a 2 wheel bike independently to increase ability to participate in age level skills
FINE MOTOR
Manipulate items at age level
move fingers dynamically with wrist stabilized to participate in fine motor activities
Demonstrate mature in-hand one handed manipulation skills (arches, translation and rotation) to participate in age appropriate fine motor skills
Have adequate tip pinch strength to manipulate items with resistance (such as wind up toys, opening packaging and holding a marker) without fatigue or thumb hyper extension (with or without adaptations such as a grip or neoprene thumb splint)
BUDDY/ SOCIAL
Respect personal space to be able to improve social interactions
Independently take turns to improve social interactions
Initiate demonstration of Empathy to improve social interactions
Be able to compromise to improve social interactions
Be able to cope with making mistakes or loosing a game without distress to improve social interactions
Be willing to try an activity within skill level perceived as difficult to improve social interactions
Initiate sharing to improve social interactions
Be able to ask to join in play to improve social interactions
Demonstrate listening position to improve social interactions
FEEDING
Interact with 8 new foods to improve feeding skills
Participates well at mealtime to try new foods
Eat 8 new foods to improve feeding skills
SELF CARE
Be calm and cooperative during all self care /management to increase ability for caregiver to complete self care tasks without resistance
Be independent with self care/management to decrease dependance on caregiver
SELF REGULATION/ZONES
Demonstrate activities to stay calm to increase activity partiicpation
Able to regulate volume of voice to increase social skills
Identifies triggers prior to escalation in OT to increase appropriate social behavior
Identify triggers prior to escalation at home to participate in self regulation strategies with minimal verbal and visual cues increasing social skills
have an 80% reduction of aggressive behavior to improve safety
COMMUNITY
Have no unsafe sensory seeking in public to improve ability to participate in community environments
Be able to be public places without distress or meltdowns to improve ability to participate in community environments
Other
PRIMARY GOALS for FUNCTIONAL IMPAIRMENT Baseline = Unable (0%). Goals are to 80% (4/5 trials) within 12 months unless otherwise stated. :
Procedures intended:
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Therapeutic Activity for improving play, social, and self regulation skills. Neuromuscular Re-education for balance and coordination Functional Movement Training. Exercises for core strength. Education on home and self-care. Home Exercises. Modalities as needed.
Specialist Recommended
Developmental Optometrist (FCOVD) comprehensive vision exam
Counseling
Physical Therapy
Other
Other notes:
Is client on an Individualized Education Plan (IEP)?
Yes
No
Other
Is there a duplication of services with the school district?
No
No, working on different goals
No, school OT services are not adequate to address the severity of the delay with minimal minutes of service and the skills are not carrying over at home.
We are working in coordination with the school OT to develop this skill.
Client is not in school
Other
Planned OT Frequency pg 4/4
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1 x per week
2 x per week
3 x per week
Other
Comments:
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Due to scheduling availability may only be 1 x per week.
Duration (in number of sessions)
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36
70
120
220
Other
Anticipated Billing Codes
OT Evaluation 97167
Developmental Testing 96112
Therapeutic Activity 97530
Neuromuscular 97112
Therapeutic Ex 97110
Self Care 97535
Feeding / Oral Motor 92526
Physical Performance Test 97750
RE- Evaluation 97168
Additional info:
Credentials
Occupational Therapy Evaluation
Therapist Name
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Mary Kostka, OTR/L
Cailyn Crossland, OTR/L
Abigail Simmons, OTR/L
Kelsey Gries, OTR/L
Other
Title
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OT
PT
SLP
Other
Date signed
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Month
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Day
Year
Date Picker Icon
Signature
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Client Name:
*
First Name
Last Name
ForPhysician Use Only (sign and fax back to 509-888-7674):
I concur with the above recommendations. Other_________________________________
Date:
Name of Doctor
Doctor Signature
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