ajaybir kalket

[email protected]

Assessment Results
Client Name: Owen- Intervention (OT)

Examination Date: February 15th, 2024

Mode: learning

Baseline Data 63/100

Collaborators 55/100

Treatment 100/100

Skills Check 83/100

Client Progress 33/100

Summary 100/100

Completion Time 84 Minutes

Your Competency Score 72%

Overall Competency Rating

Developing Competency

Skills Check
 Functional Fine Motor Tasks 77/100

Gross Motor Tasks 88/100

Completed 2 of 2

Clipboard Contents

Baseline Data
Reflective (+): 16

Acceptable (0): 0

Rejected (-): 6

Evaluation Reports

1 minutes 22 seconds

Review the Occupational Therapy Evaluation.

Enter notes in the clipboard after viewing the response.

Client Interview

5 minutes 33 seconds

To help plan activities for our time together, tell me about your
hobbies and what you like to do for fun.

I like to play video games, code, and go to the pool.

6 minutes 29 seconds

How have you been since you were here last? Do you have
anything you would like to share with me?

No, not really.

6 minutes 44 seconds

Do your di!culties with mobility embarrass you at school?

No.

6 minutes 44 seconds

Redirect #1

This interview question or objective is not appropriate for the

client.

7 minutes 0 seconds

Describe whether you have tried transcranial direct current

stimulation (tDCS) in the past to improve mobility.

What do you mean?

7 minutes 0 seconds

Redirect #2

This interview question or objective is not appropriate for the

client.

7 minutes 4 seconds

Do you get frustrated easily with challenging tasks?

Sometimes.

31 minutes 22 seconds

Describe your progress in occupational therapy so far.

I have noticed some improvements in my balance.

31 minutes 30 seconds

I read in your evaluation that you completed the constraint-

induced movement therapy (CIMT) program. Have you seen
positive results?

Yes.

Parent Interview

7 minutes 25 seconds

Do you have any new concerns about Owen you would like to
share with me?

No, Owen has been pretty much doing the same things for a while
now. Since he’s been at this therapy, we’ve kind of adjusted his
goals a bit. Primarily he’s been doing the same things, he’s been
working on the same skills and just trying to gradually improve.

7 minutes 52 seconds

Have there been any recent changes with Owen’s adaptive

equipment or devices?

We’ve had a little bit of di!culty with the AFO fit recently. Just the
new one we got because it just was a little bit too tight, and we had
to get it readjusted.

7 minutes 56 seconds

Describe any improvements you’ve noticed with Owen’s

functioning since starting therapy here.

I’ve noticed that Owen’s balance and his gait have improved in
physical therapy. It’s helped a lot with that, and occupational
therapy, he’s done a constraint-induced movement therapy
program, which has helped a lot with his right arm and two-
handed activities.

8 minutes 1 seconds

Tell me about how Owen is doing with the transition to high

school.

He is in a traditional school setting. He does regular classes and

he’s with his peers.

8 minutes 12 seconds

What does Owen do well?

Owen does everything pretty well. When he sets his mind to

something, he can do it.

8 minutes 23 seconds

What are your continued goals for Owen?

Our goals for Owen have always been to just improve his quality of
life the best we can to make sure that he can eat safely and be
mobile safely.

8 minutes 40 seconds

Does Owen receive any special services at school?

Owen is receiving special services at school. He gets a little bit of

extra time to move from class to class and he gets a little bit of
extra time to take tests or do any projects.

8 minutes 43 seconds

Are you concerned about how Owen will function in society as an

adult?
I don’t have any concerns as of right now. We’re just working on
the skills we’ve been working on for a while.

8 minutes 43 seconds

Redirect #3

This interview question or objective is not appropriate for the

client.

Session Objectives

9 minutes 28 seconds

Objective 1: Owen will complete 5 steps of a hot meal preparation

task with intermittent cues for short-term memory.

Session Objective was entered in the clipboard.

9 minutes 28 seconds

Redirect #4

This interview question or objective is not appropriate for the

client.

9 minutes 31 seconds

Objective 3: Owen will sort laundry with moderate cues for safety
using Lofstrand crutches for stability.

Session Objective was entered into the clipboard.

9 minutes 31 seconds

Redirect #5

This interview question or objective is not appropriate for the

client.

9 minutes 34 seconds

Objective 4: Owen will engage in an overhead throwing task,

focusing on shoulder external rotation with reminders for optimal
positioning and compensation no more than 50% of the time.

Session Objective was entered in the clipboard.

9 minutes 47 seconds

Objective 8: Owen will unbutton a shirt with moderate direct verbal

cues and a button hook as needed to increase participation in
dressing.

Session Objective was entered in the clipboard.

9 minutes 54 seconds

Objective 7: Owen will participate in a simple household chore task

for 5 minutes without requesting a break.

Session Objective was entered in the clipboard.

9 minutes 54 seconds

Redirect #6

This interview question or objective is not appropriate for the

client.

10 minutes 5 seconds

Objective 2: Owen will engage in a prone play activity, using both

hands together 50% of the time with moderate verbal cues for
increased participation in play.
 Session Objective was entered into the clipboard.

Collaborators
Reflective (+): 11

Acceptable (0): 6

Rejected (-): 5

Medical

12 minutes 13 seconds

You contact the Pediatrician

Hello, I'm Owen's pediatrician. How can I help you?

17 minutes 6 seconds

You contact the Pediatrician

Hello, I'm Owen's pediatrician. How can I help you?

42 minutes 6 seconds

You contact the Pediatrician

Hello, I'm Owen's pediatrician. How can I help you?

42 minutes 8 seconds

Are Owen’s vaccines up to date?

Yes, he is on track with the recommended schedule for

vaccinations and boosters.
42 minutes 9 seconds

Are Owen’s vaccines up to date?

Yes, he is on track with the recommended schedule for

vaccinations and boosters.

42 minutes 20 seconds

How do you recommend I bill for Owen’s occupational therapy

services?

That is something I can address with Owen and his parents.

42 minutes 20 seconds

Redirect #11

The is incorrect based on previous case history and/or the referral.

42 minutes 27 seconds

Are Owen’s vaccines up to date?

Yes, he is on track with the recommended schedule for

vaccinations and boosters.

Allied Professions

12 minutes 51 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

13 minutes 7 seconds
Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

13 minutes 27 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

13 minutes 51 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

14 minutes 7 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

14 minutes 26 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,
so I try to build that in when possible.

14 minutes 38 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

14 minutes 59 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

15 minutes 38 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.
20 minutes 25 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

20 minutes 37 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

20 minutes 40 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement

Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.

20 minutes 43 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.
21 minutes 18 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

21 minutes 24 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

21 minutes 25 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

21 minutes 32 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

21 minutes 41 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.
21 minutes 56 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

23 minutes 29 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

23 minutes 33 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

23 minutes 47 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

23 minutes 55 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement

Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.

23 minutes 56 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

24 minutes 5 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

28 minutes 38 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

28 minutes 44 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

28 minutes 45 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement

Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.

28 minutes 49 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

28 minutes 56 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

29 minutes 24 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

29 minutes 25 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

29 minutes 30 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

29 minutes 37 seconds
You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

29 minutes 38 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

29 minutes 40 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

29 minutes 45 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

29 minutes 52 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

30 minutes 11 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

30 minutes 15 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.
30 minutes 16 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

30 minutes 22 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

30 minutes 23 seconds

Is Owen ever bullied at school because he doesn’t communicate

normally?

It’s important that we don’t refer to Owen’s communication

abilities as normal or not normal, but instead use language that
describes a specific deficit such as dysarthria. Bullying has not
come up in my discussions with Owen or his mom.
30 minutes 23 seconds

Redirect #9

The is incorrect based on previous case history and/or the referral.

30 minutes 26 seconds

Should I discourage him from using his AAC in our OT sessions so

his verbal communication improves?

No. All clients should communicate in whatever modality they feel

most comfortable using. Owen and I will continue to address
improving his speech intelligibility in our speech therapy sessions.

30 minutes 26 seconds

Redirect #10

The is incorrect based on previous case history and/or the referral.

30 minutes 31 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

30 minutes 32 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement

Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.

30 minutes 34 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

30 minutes 35 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

30 minutes 39 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

30 minutes 40 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.
30 minutes 41 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

30 minutes 42 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

30 minutes 48 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

30 minutes 49 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

30 minutes 50 seconds
Is there anything specific I should know about when I am
communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

30 minutes 55 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

33 minutes 40 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

33 minutes 42 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement
Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.

33 minutes 43 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

33 minutes 46 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

33 minutes 59 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

34 minutes 1 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

34 minutes 4 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

34 minutes 10 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

34 minutes 11 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

34 minutes 14 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

38 minutes 59 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

39 minutes 3 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without

a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

39 minutes 4 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

39 minutes 5 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

39 minutes 6 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

39 minutes 16 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

39 minutes 18 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

39 minutes 23 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

39 minutes 28 seconds

Should I discourage him from using his AAC in our OT sessions so

his verbal communication improves?

No. All clients should communicate in whatever modality they feel

most comfortable using. Owen and I will continue to address
improving his speech intelligibility in our speech therapy sessions.

43 minutes 16 seconds

You contact the Evaluating Occupational Therapist

Hi, I've been working with Owen for the past few weeks. Thank you
for treating him today. You should have access to his initial
evaluation already. Can I help you with anything else before you
get started?

43 minutes 18 seconds

Describe Owen’s progress in occupational therapy.

He recently completed the modified Constraint Induced Movement

Therapy (mCIMT) program in our clinic. I saw big improvements
after he completed the program, specifically with bimanual
integration during functional tasks. Both his visual attention to his
right side and his shoulder range of motion have improved but
remain goals. His low tone continues to a"ect optimal positioning
with ADLs.
43 minutes 19 seconds

What motivates Owen the most in your sessions?

He really loves anything related to using technology and gaming,

so I try to build that in when possible.

43 minutes 20 seconds

Is there anything specific you would like me to focus on in my

session with Owen?

Yes! It would be helpful if you could incorporate upper extremity

weight bearing and also encourage him to use both hands if that
fits into your interventions. We typically have time for two or three
activities that focus on a combination of prerequisite exercises and
functional tasks.

43 minutes 23 seconds

You contact the Physical Therapist

Hi, I'm from the physical therapy department. I'll be working with
Owen in his session today. I sent a copy of his physical therapy
initial evaluation to your clipboard. How can I help you?

43 minutes 30 seconds

Describe Owen’s progress in PT so far.

He is making slow but steady progress with his balance. His short-
and long-term goals are still appropriate. He enjoys golf and wants
to golf on his own, but he needs to work on his balance before he
is able to swing the golf club independently.

43 minutes 31 seconds

Are there any significant concerns with Owen’s balance?

According to his prior notes, he ambulates independently without
a history of falls. His right side is weaker, and his PT interventions
include single stance exercises to strengthen his right leg.

43 minutes 37 seconds

How will you plan to communicate with Owen during your session?

Owen uses a chat feature on his iPad to communicate. This is what

I plan to use. Perhaps we can discuss his progress together after
we both see him?

43 minutes 42 seconds

You contact the Speech-Language Pathologist

Hello, I'm Owen's speech therapist. I sent a copy of Owen's

evaluation to your clipboard for review.

43 minutes 43 seconds

I understand that Owen uses an augmentative and alternative

communication (AAC) device to communicate. Can you tell me
more about it?

Sure. Owen has used a speech generating device (SGD) for several
years. Owen uses a text-to-speech device where he can type words
that he wants to say or choose from prewritten messages. His
device also o"ers word prediction to speed up communication.
Once Owen has typed his message, his device generates audible
synthesized speech. Owen uses his device independently.

43 minutes 44 seconds

Is there anything specific I should know about when I am

communicating with him during his OT sessions?

It is important to note that Owen communicates using both verbal

speech and his AAC device. In addition to a social-cognitive
impairment, Owen presents with flaccid dysarthria, which
significantly reduces his speech intelligibility. During your session,
please keep his device close by so that he can access it at any time.
Regardless of whether he communicates verbally or with his AAC,
make sure that you give him plenty of time to respond to your
questions or feedback and try to avoid finishing his sentences for
him. Owen has a fun, social personality. He is usually engaged and
follows commands well.

43 minutes 45 seconds

Should I discourage him from using his AAC in our OT sessions so

his verbal communication improves?

No. All clients should communicate in whatever modality they feel

most comfortable using. Owen and I will continue to address
improving his speech intelligibility in our speech therapy sessions.

43 minutes 46 seconds

Can Owen take water breaks during an OT session? Sometimes we

really get our heart rates up.

That should be okay for now, with some precaution. Owen and his
mom report he occasionally coughs with thin liquids, and it is
recommended that he uses a straw to drink as he does so at
home. I will let you know if there are any new recommendations
following his next modified barium swallow study (MBSS). Please
let me know if he coughs a lot or experiences a wet, gurgly
sounding voice after drinking water during your session.

Community

16 minutes 13 seconds

You contact the Friend

Hi, I'm Owen's best friend.

16 minutes 13 seconds

Redirect #7

The is incorrect based on previous case history and/or the referral.

Educational

16 minutes 18 seconds

You contact the School Special Education Coordinator

Hello, I coordinate services for students at Owen's school.

16 minutes 33 seconds

What accommodations does Owen receive?

Owen receives extra time for tests, moving between classes, and
completing projects.

16 minutes 39 seconds

How would Owen apply for more services?

I can work with Owen and his family to obtain more services, but
the recommendations would have to come from his updated IEP. I
have not received any updates recently.

16 minutes 48 seconds

Are you concerned that Owen is in a traditional classroom setting?

No, I am not concerned. He is doing well in school, and I haven’t

received any communications from him or his teacher indicating
that he requires a di"erent setting at this time.
 16 minutes 48 seconds

Redirect #8

The is incorrect based on previous case history and/or the referral.

17 minutes 3 seconds

You contact the School Special Education Coordinator

Hello, I coordinate services for students at Owen's school.

Treatment
Therapeutic Activities

42 minutes 53 seconds

Functional Fine Motor Tasks

1 hours 4 minutes 58 seconds

Gross Motor Tasks

Client Progress
Client Progress

1 hours 17 minutes 21 seconds

2. Goal Met: Owen will engage in a prone play activity, using both
hands together 50% of the time with moderate verbal cues for
increased participation in play.
1 hours 17 minutes 27 seconds

2. Goal Not Met: Owen will engage in a prone play activity, using
both hands together 50% of the time with moderate verbal cues
for increased participation in play.

1 hours 17 minutes 27 seconds

Redirect #12

This statement does not reflect the client’s current progress.

1 hours 17 minutes 32 seconds

2. Goal Not Targeted: Owen will engage in a prone play activity,

using both hands together 50% of the time with moderate verbal
cues for increased participation in play.

1 hours 17 minutes 33 seconds

Redirect #13

This statement does not reflect the client’s current progress.

1 hours 18 minutes 0 seconds

3. Goal Not Targeted: Owen will sort laundry with moderate cues
for safety using Lofstrand crutches for stability.

1 hours 18 minutes 17 seconds

4. Goal Met: Owen will engage in an overhead throwing task,

focusing on shoulder external rotation with reminders for optimal
positioning and compensation no more than 50% of the time.
 1 hours 18 minutes 30 seconds

5. Goal Not Targeted: Owen will identify 50% of his medications by

name and will sort medications using a pill organizer with minimal
direct verbal cues.

1 hours 18 minutes 41 seconds

6. Goal Not Targeted: Owen will independently propel his

wheelchair in a community setting during 2 out of 3 opportunities.

1 hours 19 minutes 6 seconds

8. Goal Met: Owen will unbutton a shirt with moderate direct

verbal cues and a button hook as needed to increase participation
in dressing.

1 hours 19 minutes 30 seconds

1. Goal Not Targeted: Owen will complete 5 steps of a hot meal

preparation task with intermittent cues for short-term memory.

1 hours 20 minutes 9 seconds

7. Goal Not Targeted: Owen will participate in a simple household

chore task for 5 minutes without requesting a break.

Summary
Summary
 1 hours 23 minutes 6 seconds

Owen met 3 session objectives today. Given up to moderate direct

verbal cues to minimize compensation and engage bilateral upper
extremities during at least 50% of attempts, he participated in
prone and seated play activities with the goal of improving
independence with overhead reaching. Owen also worked on
dressing skills today. He unbuttoned his shirt with intermittent use
of a button hook and required minimal cueing for bimanual
technique. Continue plan of care without modification.

Documentation

Document the encounter / Enter applicable billing codes:

Enter/Update Long and Short Term Goal(s):

Skills Check

Functional Fine Motor Tasks

Review Owen’s OT evaluation and describe why Owen may benefit from adaptive
equipment or strategies to manipulate small buttons.

A. Cutting paper using scissors

B. Maintaining core control in a prone position

C. Grasping and tracing shapes

D. Static sitting in an adaptive stroller

 E. increase independence in dresasing

Which of today’s selected session objectives relates to fine motor tasks?

A. Grasping a writing utensil

B. Tracing letter shapes

C. Managing buttons and using a button hook Correct

D. Manipulating a video game controller

Owen’s goal for fastener management relates to:

A. On-body orientation; Owen should wear personal clothing during the task.
Correct

B. O"-body orientation; Owen should use a button board or simulated clothing

item.

What materials will you need for this task? Select all that apply.

A. Adaptive zipper pull

B. Button hook Correct

C. Video game controller

D. Writing claw

E. Clothing item with button fasteners

Manipulating a button hook with greater independence will help Owen improve
participation in which functional task?

A. Grooming

B. Dressing

C. Driving

D. Bathing Incorrect

Which factors will help you measure Owen’s performance with button
management? Select all that apply.
 A. The speed with which he unbuttons buttons

B. Whether he is able to verbalize the steps of the task

C. The amount of cueing required to increase participation

D. The success rate when unbuttoning buttons with or without the adaptive
device Correct

Owen is seated at the edge of a backless bench. Describe the postural challenge
level and potential impact on task performance.

A. Palmar supinate and tripod

B. Digital pronate and quadrupod

C. Quadrupod and tripod

D. Palmar supinate and digital pronate

E. low BUE and decrease muscular strength in trunk

Why is Owen set up in front of a mirror during this task? Select all that apply.

A. To provide visual feedback about his posture Correct

B. To assist with treatment of phantom limb pain

C. To assist with visual attention

D. To provide an immersive virtual experience

With which hand is Owen more likely to have control when manipulating fasteners?

A. Right

B. Left Correct

C. Neither right nor left

Owen is using his left hand to manipulate the button hook. Identify his grasp
pattern.

A. Lateral grasp

B. Tripod grasp
 C. Digital grasp

D. Radial palmar grasp Correct

Describe Owen’s performance during this segment.

A. Owen buttons one button with moderate direct verbal cues and a button hook.

B. Owen unbuttons one button using a button hook and moderate direct verbal
cues for attention to task.

C. Owen unbuttons one button using a button hook and minimal direct cues to
incorporate the right hand. Correct

D. Owen unbuttons one button using a button hook and maximal direct verbal
cues for emotional regulation during the task.

What other strategies may improve Owen’s independence with this task?

proximal support at the elbow or trunk

Owen struggles to use the button hook. What postural strategy or position may
help?

A. Weighted support at the ankles to improve motor control

B. Lying supine on a wedge pillow

C. Long sitting on a mat or floor surface

D. Proximal support at the elbows or trunk to improve motor control Correct

During this task, Owen’s right hand functions as:

A. Nonfunctional; no active movement and the UE is not incorporated into daily

activity.

B. A dependent stabilizer; UE is incorporated into activities as a stabilizer when

placed by the other UE or caregiver.

C. An independent stabilizer; there is some movement where the client

independently positions the UE and it functions primarily as a weight to
stabilize.

D. A gross assist; gross grasp is assisted by synergistic movement with limited

 fine motor abilities. Correct

Describe Owen’s performance during this segment.

A. Owen buttons one button with moderate direct verbal cues and a button hook.

B. Owen unbuttons one button with minimal direct cues for motor control and
to incorporate the right hand. Correct

C. Owen unbuttons one button using a button hook and moderate direct verbal
cues for attention to task.

D. Owen unbuttons one button using a button hook and maximal direct verbal
cues for emotional regulation during the task.

Does Owen meet the session objective for unbuttoning buttons with moderate
direct verbal cues and a button hook as needed?

A. Yes Correct

B. No

Owen unbuttons the top button of his shirt without adaptive equipment. What
should this observation prompt you to do?

increase bi lateral cordination

Owen performs the task with increased e!ort and time. Identify appropriate
compensatory options that are available should he want to consider them. Select all
that apply.

A. Adaptive hook and loop closures

B. Elastic laces

C. Adaptive velcro closures

D. Large button closures Correct

How will you upgrade or downgrade this activity in a future session to work toward
long-term goal attainment?

with the size and number of buttons

Gross Motor Tasks

Based on Owen’s evaluation reports on file, which factors have not impacted his
gross motor development? Select all that apply.

A. Low core muscle tone

B. Spastic diplegia

C. Flaccid dysarthria

D. Cognitive impairment Correct

Which of today’s selected session objectives relate to gross motor skill

development? Select all that apply.

A. Overhead throwing activity with the focus on external rotation

B. Unbuttoning fasteners on a shirt with adaptive devices

C. Household chore task without requesting rest breaks

D. Prone play-based exercise with the focus on bimanual incorporation Correct

Increasing shoulder external rotation, as targeted during an overhead throwing

activity, will improve Owen’s independence with daily activities. Which daily activity
does not require external rotation?

A. Combing the back of one’s hair

B. Threading one’s arms into a shirt or jacket

C. Tucking a shirt into the back of one’s pants Correct

D. Reaching diagonally into an overhead cabinet

What measure will you use to determine whether the session objective related to
the overhead throwing activity has been met?

A. The percentage of time that cueing is required to minimize postural

compensation Correct

B. The distance that Owen throws the ball

C. The amount of repetitions completed within a five-minute time frame

D. The accuracy of the throw as measured by distance from the target

Activities in prone are most likely to assist Owen with developing:

A. Walking speed.

B. Fine motor skills and dexterity.

C. Emotional regulation skills.

D. Core stability and strength. Correct

What measures will you use to determine whether the session objective related to
prone play has been met? Select all that apply.

A. The percentage of time Owen uses both arms in the activity Correct

B. The amount of cueing required throughout the activity Correct

C. The distance that Owen independently crawls

D. The amount of physical assistance required to initiate each component of the

activity

Owen is positioned with each ball to his right, and he aims forward at a target with
his right arm. The reaching portion of this exercise encourages increased:

A. Internal rotation of the right shoulder. Incorrect

B. Extension of the right shoulder.

C. External rotation of the left shoulder.

D. External rotation of the right shoulder.

What performance skills does this throwing activity target? Select all that apply.

A. Positioning Correct

B. Reaching Correct

C. Walking

D. Bending

E. Speaking fluently
 F. Gripping Correct

Owen struggles with releasing the ball at times. Describe one potential cause.

A. Reaching

B. Rolling

C. Shoulder stabilization

D. Standing

E. Trunk and neck extension

F. spasticity of RUE

Describe Owen’s performance.

A. Owen completes 2 repetitions with cueing at least 25% of the time to minimize
postural compensation.

B. Owen completes 4 repetitions with cueing at least 25% of the time to minimize
postural compensation.

C. Owen completes 8 repetitions with cueing at least 25% of the time to minimize
postural compensation.

D. Owen completes 9 repetitions with cueing at least 50% of the time to

minimize postural compensation. Correct

To generalize skills learned to the home environment, Owen should focus on:

A. Self-monitoring to reduce postural compensation. Correct

B. Indicating the presence of pain before it interferes with functioning.

C. Desensitizing the limb prior to exercise or daily activity.

D. Procedural memory by writing down and reciting the steps.

Owen is asked to reach across his body to retrieve each ball prior to throwing it
forward at a target with his right arm. The reaching portion of this exercise
encourages increased:

A. External rotation of the right shoulder.

 B. Extension of the right elbow. Correct

C. External rotation of the left shoulder.

D. Extension of the left elbow.

Another term for reaching across the body is crossing:

A. Trendelenburg.

B. Prone.

C. Midline. Correct

D. Supine.

Describe Owen’s performance.

A. Owen completes 2 repetitions with cueing 100% of the time to minimize

postural compensation.

B. Owen completes 8 repetitions with cueing 50% of the time to minimize postural
compensation.

C. Owen completes 9 repetitions with cueing 25% of the time to minimize

postural compensation. Correct

D. Owen completes 12 repetitions with cueing 75% of the time to minimize

postural compensation.

Incorporating Owen’s augmentative and alternative communication device (AAC)

into this conversation supports which occupation?

A. Communication management Correct

B. Intimate partner relationships

C. Sleep preparation

D. Nutrition management

Describe the importance of designing treatment interventions that align with a

client’s preferred activities and occupations.

helps to get client more engaged and motivated witch will eventually increase
clients satisfaction.
Which choices are benefits from Owen crawling prone on a scooter board? Select all
that apply.

A. Bilateral coordination Correct

B. Lower extremity strength

C. Proximal joint stability Correct

D. Motor planning Correct

E. Finger isolation

Describe Owen’s performance.

A. Owen completes 1 repetition with cueing 75% of the time to incorporate

bilateral upper extremities into the task.

B. Owen completes 3 repetitions with cueing 50% of the time to incorporate

bilateral upper extremities into the task. Correct

C. Owen completes 3 repetitions with cueing 100% of the time to incorporate

bilateral upper extremities into the task.

D. Owen completes 9 repetitions with cueing 25% of the time to minimize postural
compensation.

The task is upgraded by asking Owen to:

A. Use only his legs to propel his body backward.

B. Use only his right arm to crawl forward.

C. Position the bowling pins independently. Correct

D. Position his arms in an elbow-prop.

Does Owen meet the session objectives related to gross motor skill development?

A. Yes Correct

B. No

Because the measures used to determine goal attainment today are based on level
of cueing rather than physical assistance, what is a reasonable area to focus on
next?

A. Encouraging Owen to ask for assistance before errors are made

B. Rewards and punishment

C. Emotional regulation

D. Metacognition and self-correction Correct

Identify two occupation-based activities to engage Owen during a future session

that address gross motor skill development and will upgrade the challenge
presented today.

A. Single-limb stance

B. Double-support stance

C. picking up di"erent balls and throwing them on a target