Treatment Plan Session 6

INTERVENTION PLAN FOR COMMUNITY CLIENT WITH REFLECTION

Copy/paste one LTG and the matching STG from your evaluation SOAP note. This will be the goal set around which you design your treatment session.
For this and all subsequent weeks, please answer the following questions before designing your treatment plan for the next week. If you were unable to see your
client the past week, you do not need to answer these questions. Answer the questions based on the treatment that you implemented:

What went well with your treatment? Did things go as you planned or not? Explain. What will you do differently with this next treatment plan?

Reflection of Previous Session:

Eliminating the heated appliances for a session was useful to allow for more problem solving and repetition of specific movements with fewer limitations
from safety precautions. The client has identified a goal of completing meal prep activities that require the use of a stove or oven, so we plan on preparing
everything and putting it into the pot at the table or counter and then transferring the pot to the stove. This way he can work toward meeting his personal
goal with modifications to the sequence and type of meals without the safety risks of working at the stove. We were excited that he showed less impulsivity
in the amount of condiments that he used on the sandwich which has been an issue in previous activities (with paint and batter).

The clean up activity worked well as the task was familiar enough for him to get repetitive motions in his shoulder with cueing to limit shoulder hiking.
Using the dish washing wand allowed him to use his L UE functionally while focusing on shoulder movements. When wiping down the table he wasn’t very
effective but showed signs of fatigue and increased tone in his hand after completing other activities. He seemed to lack motivation during this component
which is uncharacteristic. Recognizing his fatigue and frustration with being unable to extend his L hand, even in weight bearing, should have influenced
how we completed the last 5 minutes of the session. We should have graded the activity down, or spent more time washing the dishes since he was
challenged but not frustrated during this activity. This was an important realization for me to ensure that I am modifying my treatment plans to the specific
needs during the session instead of rushing through to complete everything I had planned.

Long-Term Goal: Within 6 weeks client will safely prepare a 5-step stovetop meal with SBA.

Short-Term Goal: Within 3 weeks, client will improve LUE AROM to complete a simple bilateral meal prep with MinA.

OCCUPATIONAL OPM and CPM TREATMENT SESSION GRADING THE ACTIVITY

PERFORMANCE PROBLEM
Specifically identify only the client
factors and/or performance skills
that are barriers to the
achievement of this goal. This
should not be a bullet list, rather
you should describe how the client
factor impacts this client’s
performance of the occupation in
the goal.
AND RATIONALE
Identify your OPM and all relevant
CPM’s that best addresses the
performance problem and describe
how each will be used to design
treatment for this client’s specific
problems.
DESCRIPTION
Provide details of how you will set up
the activity and how your intervention
addresses the performance problem.
Your description should detail how the
activity will be set up to make it
therapeutic.
Choose one client factor or
performance skill that you address
in your treatment session. Describe
one way (only one) that you can
grade the activity up and one way
(only one) to grade the activity
down based on that one factor or
skill.
Factor/Skill: grip

The client’s high tone in his LUE
has limited his ability to use and
manipulate cooking tools,
containers, and ingredients. This is
especially evident in his dexterity
with opening packages. He shows
deficits in his L supination, grip,
release, and elbow flexion.
Consistent with his diagnosis of a
R CVA, he shows deficits in
problem solving and utilizes
inefficient strategies. His
ineffective strategies have involved
situating and using materials/tools
ineffectively, and taking an
excessive amount of time to
complete tasks.
He shows an emergent awareness
of his deficits, but a lacks
anticipatory insight. He has also
displayed impulsivity which
functions as a safety concern
when working with heated
appliances and sharp tools.
Another skill that influences the
client’s effectiveness in meal prep
is his lack of attention to task.
During previous occupational
observations client regularly
interrupted task progression to
carry on with irrelevant
conversation.
PEO: This activity is part of a
valued occupation that the client
has communicated but wasn’t
ranked as a top priority during the
mCOPM. By using this activity, we
can make the movements and
problem solving purposeful and
client centered while address client
factors and performance skills that
assist in his meal prep goals.
We will be completing this activity at
his home and with his personal car.
This is an excellent opportunity to
incorporate his personal
environment and help problem
solve ways for him to safely
participate in this desired
occupation. In that way we are
improving the congruency between
his personal and environmental
contexts with this desired
occupation. The client has also
made multiple comments recently
about feeling “useless” around the
house and not being able to
participate in home/yard/car
maintenance like he used to is
“frustrating” and “humiliating”. This
activity will serve to give him an
opportunity to teach us about
something that he is knowledgeable
about, provide the opportunity to
work on performance deficits, and
hopefully contribute to his sense of
self-efficacy and purpose. This will
be done by using a client-centered
approach which is a key component
of PEO.
Motor Control- This practice model
will be utilized to provide movement
repetition while assisting the client
in learning the entire task, rather
Treatment Plan Session 6
Session will take place at client’s Down: when removing lid from
house as it is our community session. windshield wiping container,
Client will be instructed to actively use maintain a static grip with L hand
his LUE as much as possible while rotating the container with the
throughout the activity. After having R.
utilized his active movement available
in his LUE, he will use his RUE to
complete the movements &/or place Up: Use L UE to unscrew the
objects in his RUE. windshield wiper cap under the
hood, requiring pt to maintain grip,
Before starting the task, have the pronation, shoulder and elbow
client complete a pre self-assessment extension during wrist deviation
to practice anticipatory awareness of movement. This will provide
functional deficits specific to this task. functional movement outside of his
synergistic pattern.
If the client’s car has ice or snow on it,
the OTS will set up the activity by
scraping off the windshield. OTS will
also assist in opening and closing the
hood during these activities to
prioritize the client’s participation
within the time frame on other
activities.
Provide winter windshield cleaner in a
squirt bottle and a dry hand towel.
Instruct the client to actively open his L
hand around the bottle as much has
he can then, if needed, use R hand to
help place the bottle in his grip. To
complete finger flexion & extension
when spraying the cleaner, OTS will
provide hand-over-hand assistance as
needed after client’s movement
initiation.
Starting on the passenger side, the
client will use his R hand to place a
cloth in his L hand. He will use active
extension of fingers with L forearm in
pronation. Client will then use a fisted
grip of the cloth to wipe down the
windshield. He will maintain shoulder
flexion and use elbow flexion and

than discrete parts. This uses
principles of neuroplasticity to
improve the client’s neuromotor
function that has been affected by
his stroke. The repetitive
movements during this clean up
activity correlate with the
neuromotor function that we are
working to improve for his meal
prep and dressing goals.
DIM- We will utilize the Dynamic
Interactional Model of Cognition to
provide cognitive strategies that
improve his occupational function.
We will utilize anticipation, pre &
post self-assessments, and self-
questioning. Specifically, with
cooking we will use this to improve
his insight, awareness of safety
concerns, and attention to task.
NDT- We will utilize intermittent
stretching as a preparatory method
to implementing bilateral task
specific training, and weight bearing
to provide proprioceptive feedback
through his LUE.
Treatment Plan Session 6
extension to move the cloth in a closed
chain against the windshield.
Assistance to maintain shoulder
flexion without hiking will be given. He
will be able to lean on the car as
necessary and use the R UE to
stabilize on the hood of the car. After
he finishes with his L UE, he will be
given the chance to use his R UE to
complete wiping down the passenger
side with his L UE resting on top of the
roof or against the side of the car.
To complete the driver’s side, client
will utilize the same technique with
active extension of L fingers and assist
from R hand to place the cloth in his L
hand. On this side, the client will place
his R hand on the roof of the car or the
edge of the windshield while wiping
down the windshield with his L UE.
Once complete, client will place L
hand in extension to weight bear with
palm down on the hood while he uses
his R UE to complete the task of
wiping down his windshield.
The client will then be asked to show
us how to check the oil and fill
windshield washer fluid. Client will
once again use active extension to
place a cloth in his L hand, but his
forearm will be supinated. He will be
asked to use his R UE to remove the
oil dip-stick and his L hand to maintain
supination while sliding cloth across
the oil dip-stick. He will then re-insert
and remove the dipstick with his R UE
to check the oil level.
Lastly, the client will be given a
partially full gallon sized container of
windshield wiper fluid. He will place his
L UE in weight bearing with palm down
 Treatment Plan Session 6

while locating and unscrewing the

correct cap with his R hand. The client
will remove the lid of the fluid container
with his L hand, while stabilizing the
bottle with his R. He will then grasp the
fluid container by the handle with his R
hand, and if his dynamic standing
balance is adequate, he will be
encouraged to use his L hand under
the bottom of the container to assist in
pouring the liquid.

After the activity is complete, the client

will be asked to do a post self-
assessment by identifying what went
well, what was difficult, and if his
performance was what he expected.
 Home Program Session 6

SOAP Note

Session 6

S: Client reported that relying on his wife to unclog the toilet this week “was humiliating”.

O: After preparatory PROM client prepared a hoagie sandwich and cleaned up afterward. He successfully

utilized a lateral pinch to I’ly open turkey packaging and carry plates with both hands, but couldn’t maintain this

grip when pulling against resistance to open bread-bag fastener. He required MinVP to open condiment flip top

bottles and to incorporate L UE throughout the meal prep activity. Client required physical guidance to reposition

when cutting toward himself with the knife. When cutting the sandwich into thirds, client smashed the sandwich

with his L stabilizing fist.

At the sink, he used a pronated L fist to manipulate the faucet lever. To wring out excess water from a

hand-towel he placed it in L fist with R hand and required ModA to release and tighten his grip around the cloth.

After struggling to weight bear through L UE while wiping down the table with his palm down, the client used a

lateral pinch to grip the cloth while whipping the towel forward and sliding it back toward himself to collect the

excess food on the table. When finished, remnants from meal prep remained on the table. To wash dishes, client

used R hand to place dish washing wand in L hand. He required VP to prevent shoulder hiking and to move the

wand on plate, as opposed to plate on wand.

A: While client has displayed impulsivity when pouring and using excess material in previous sessions, he

used a reasonable amount of condiments and soap today. While this shows an improvement, he continues to show

some impulsivity and decreased safety awareness in using the knife to cut toward himself. His ineffective

strategies for cutting the sandwich and wiping down the table show a continued deficit in problem solving. His

supination, elbow flexion, flinger flexion & extension all continue to limit his functional movement,

P: Continue use of preparatory activities to temporarily reduce tone before engaging in bilateral task specific

training for meal prep and dressing. Continue to assist client in improving his anticipatory insight and problem

solving with pre & post self-assessments. Utilize cognitive strategies to address client’s impulsiveness and safety

concerns.
 Home Program Session 6

Signed: ___________________________________Angie Blaser OTS____ Date: 2/22/18

Goals:

• LTG 1: Within 6 weeks, client will I’ly complete upper body dressing utilizing compensatory strategies
within a reasonable amount of time per client report.

o STG 1a: Within 4 weeks client will fasten all buttons on a shirt, with Min physical assistance to
incorporate his LUE and AE as needed.

o STG 1b: Within 4 weeks client will improve grip with his L. hand to don a tie with min VP.
 Met 2/08/18

• LTG 2: Within 6 weeks client will safely prepare a 5-step stovetop meal with SBA.

o STG 2a: Within 3 weeks, client will use sharp kitchen tools to open packages with Min VP for safety.

o STG 2b: Within 3 weeks, client will improve LUE AROM to complete a simple bilateral meal prep
with Min physical assistance.
 Home Program Session 6

Home Program
1. Daily stretching – refer to handout
*hold each stretch for 10 seconds

2. Eating- use “Lefty” to eat meals

*Keep left elbow on table
*Sit upright
10 times in 3 weeks 

3. Dressing-
1 time a week, complete following chart:

Time How’d it Explain

go? (+, ~, -)
Week 1

Week 2

Week 3

+ = good ~ = okay - = not very good

 Home Program Session 6

Finger Flexion / Extension

Starting position: □ Lying on back □ Lying on less affected (right / left) side □ Sitting

Repeat 20 times.

1. Begin by placing your affected (right/left) hand on your lap or a table.

2. Use your less affected (right/left) hand to bend all the fingers of
your affected (right/left) hand until your fingertips touch your
palm.
3. Use your less affected (right/left) hand to open all the fingers of
your affected (right/left) hand so they are straight.

Elbow Flexion / Extension

Starting position: □ Lying on back □ Lying on less affected (right / left) side □ Sitting

Repeat 20 times.

1. Bend your elbows to bring your hands toward your chest. Try to touch your chin.
2. Straighten your elbows. Attempt to straighten both elbows fully.
 Home Program Session 6

Wrist Flexion / Extension

Starting position: □ Lying on back □ Lying on less affected (right / left) side □ Sitting

Repeat 20 times.

1. Keep your elbows bent and close to the side of your body, with your hands pointing
forward.
2. Use your less affected (right/left) hand to bend your affected (right/left) wrist to the
left .
3. Use your less affected (right/left) hand to bend your affected (right/left) wrist to the
right.

Forearm Supination / Pronation

Starting position: □ Lying on back □ Lying on less affected (right / left) side □ Sitting

Repeat 20 times.

1. Keep your affected (right/left) elbow bent and close to the

 Discharge SOAP Note

side of your body, with your hands pointing forward.

2. Use your less affected (right/le ft) arm to rotate your affected
(right/left) arm so the palm faces upward.
3. Use your less affected (right/le ft) arm to rotate your affected
(right/left) arm so the palm faces downward.
 Discharge SOAP Note

OCCUPATIONAL THERAPY DISCHARGE NOTE

BACKGROUND INFORMATION

Date of Report: 4/12/18 Client’s name: Kent Anderson

Age: 72 Date of referral: 01/11/18
Primary diagnosis/concern: R CVA 07/04/2016
Precautions/contraindications:
Reasons for referral to OT: L UE motor control
Therapist: Angie Blaser OTS

S: “I really appreciate all you girls have done for me, I’m going to miss coming here.” “Look at

what I can do now!” when actively raising LUE through functional limits of shoulder flexion.

O: Client was seen 1x/wk for a total of 8 visits at the Life Skills Clinic for skilled Occupational

Therapy services. Client completed PROM of L UE at the beginning of each session in preparation

for functional activities. Task specific training and cognitive strategies were utilized to address his

deficits in process skills and motor control.

The Modified Ashworth Scale quantifies muscle tone during quick PROM. This assessment was

completed at initial and discharge evaluations, showing the following progress:

INITIAL EVAL GRADE RE-EVAL

0: no increase in tone;
4: rigid tone

R UE: all movements 0 R UE: all movements

L UE: pronation, finger flexion, L UE: pronation, finger flexion,
elbow extension, wrist flexion elbow extension, wrist flexion

L UE: wrist extension, elbow 1 L UE: wrist extension, elbow

flexion, shoulder horizontal flexion, shoulder horizontal
adduction adduction, supination, shoulder
flexion

L UE: supination, shoulder 2

flexion

3 L UE: finger extension

L UE: finger extension 4

 Discharge SOAP Note

The following progress was made toward the client’s collaboratively established goals:

Long Term Goals Initial Performance Final Performance

By discharge, client Client reported that dressing took Client I’ly donned a button-up shirt
will I’ly complete an excessive amount of time, up to and tie, using a button hook, in 11
upper body 1.5 hrs for formal church dress. minutes.
dressing utilizing
compensatory He was observed donning a snap- At discharge he self-reported
strategies within a up shirt in 7 minutes. He used 1 completing his formal church
reasonable amount handed techniques with moderate dressing routine within 30 minutes.
of time, per client effectiveness and required regular
report. breaks.

By discharge, client During pre and post self-
will safely prepare assessments, client could not
a 5-step stovetop identify any areas of difficulty. He
meal with SBA. positioned knives and scissors
toward himself when cutting food
and opening packages. He cut his
L thumb when opening a can, and
attempted to place the food into
the oven while leading with his
affected LUE. Throughout the
entire task he required Mod
physical assist, physical guidance
to grasp scissors correctly, and
continuous v/c for safety.
Goals:
During pre self-assessment of a 5-
step stovetop meal prep, client I’ly
identified that the stovetop tasks
may be difficult for him to
complete and he expressed the need
to use caution for those steps.
Client followed the recipe and
opened all packages, using sharp
kitchen tools, without any v/c for
safety. With the exception of
requiring MinA to safely transport a
bowl of hot food from the
microwave > table, he successfully
completed the meal prep with SBA.

• LTG 1: Within 2 sessions, client will I’ly complete upper body dressing utilizing compensatory
strategies within a reasonable amount of time per client report. Met 04/12/18

o STG 1a: By next session client will fasten all buttons on a shirt, with Min physical assistance to
incorporate his LUE and AE as needed. Met 02/22/18
o STG 1b: Within 4 weeks client will improve grip with his L hand to don a tie with min
VP. Met 2/08/18

• LTG 2: Within 2 sessions client will safely prepare a 5-step stovetop meal with SBA. Partially Met
04/12/18

o STG 2a: Within 2 sessions, client will use sharp kitchen tools to open packages with Min VP for
safety. Met 3/30/18

o STG 2b: Within 2 sessions, client will improve LUE AROM to complete a simple bilateral meal
 Discharge SOAP Note

prep with Min physical assistance. Met 04/12/18

A: The client actively progressed toward his goals, displaying improved motor control and

decreased tone in his L UE. Improvement of the client’s insight, problem solving, and

impulsivity increased his safe functioning and independence in desired occupations.

P: Skilled outpatient OT services are recommended to continue improving his LUE motor control

and improve his performance in client centered goals not prioritized or directly addressed during his

community client intervention. It is recommended that the client also continue attending community

programs, such as his current involvement in boxing and ballet classes for stroke rehabilitation.

Signed: Angie Blaser OTS Date: 4/12/18