Occupational Therapy Evaluation

Client: Raymond Schuler Date of Service: December 6, 2019

Age: 7 years, 2 months, and 2 days Therapist: Sarah Layton, OTS

REASON FOR Raymond’s mother is seeking OT services to ensure Raymond has the
REFERRAL best opportunity for success in life. Due to recent success in her
husband’s business they have more money to dedicate to OT services.

Primary Diagnosis Autism Spectrum Disorder

Other demographic Raymond has a twin brother named Ronald

information Raymond’s family consists of his father, mother (Amy), older brother
(Randy), twin brother (Ronald), younger sister (Rachel), and younger
brother (Ricky)
Raymond’s family lives close to extended family

Evaluation

Occupational profile: Commented [SG1]: When writing, try not to start every
Raymond is a 7 years, 2 months, and 2 days old male diagnosed with Autism Spectrum Disorder sentence the same. Right now most sentences start with
Raymond.
at age 4. Raymond’s mother is seeking OT services to ensure Raymond has the best opportunity
for success in life. Due to recent success in her husband’s business they have more money to
dedicate to OT services. Raymond is currently receiving limited occupational therapy services
through the school.
Raymond is successful in many occupations. Raymond is able to complete the self-care tasks of
bathing including hair washing with minimal supervisor for cleanliness and independently
toilets. However, Raymond does have a hard time with the self-care tasks of brushing his teeth
(ensuring all teeth get cleaned), dressing when clothing has fasteners, and putting on and tying
his shoes. As well as, self-feeding with utensils. Mother reports Raymond has a difficult time
manipulating the tools necessary for these tasks such as utensils and toothbrush. Raymond is
successful in getting around his house and the community. Raymond is successful in playing
with himself and his siblings. Raymond communicates well with his family but has a difficult
time interacting with peers he does not know. Raymond is home schooled and performs well in
school. Raymond is able to focus on tasks with the support of his siblings nearby and complete
assignments in a timely manner. Raymond does have difficulty with handwriting, cutting, and
coloring and mother states it takes him a long time to complete. Raymond has no problems with
sleep. Raymond has a supportive social environment consisting of his family and nearby
extended family. Raymond lives in a supportive physical environment with all the supplies
necessary for development. Raymond has a limited social environment with peers outside of his
family and mother states he does not have friends.
Raymond was born-full term with no complications during pregnancy or birth. Raymond was
slightly slow at meeting major developmental milestones. Raymond received early intervention
OT services and met all developmental milestones. Raymond enjoys playing on the x-box but his
parents limit his screen time to only once a week for two hours because it can be a distraction.
Raymond’s daily life roles are son, brother, student, and cousin.
Raymond has a consistent daily schedule and responds well to set morning, school, and night-
time routines. Raymond’s mothers desired priorities for occupational therapy consist of
socializing with peers, brushing his teeth, dressing with fasteners and putting on his shoes,
feeding with utensils, and complete of the school skills of writing, cutting, and coloring.

COPM:
Raymond’s mom completed the Canadian Occupational Performance Measure (COPM), which
is an assessment that identifies top priorities for goals and outcomes as well as the perception of
the current performance, and performance over time in each specified area. The following items
were indicated as highest areas of concern (in order of most important to least important):
OCCUPATIONAL Impt PERFORMANCE SATISFACTION
PERFORMANCE
PRIORITIES
Socializing with Peer 10 4 5
Brushing Teeth 8 4 5
Dressing with Fasteners, putting 8 7 5
on shoes
Feeding with utensils 8 4 5
School tasks of writing and 8 7 5
cutting
TOTAL 26 25
Average Scores 5.2 5

Observation of occupational performance:

Raymond was observed putting on a jacket outside. Raymond had the coat over his head and was
trying to locate the head hole. Raymond found the head hole after spinning coat twice. Raymond
undid the Velcro and pulled head through head hole. Raymond was observed putting on socks.
Raymond used both hands to open sock mouth and place on foot. After putting on both socks,
Raymond stood up and walked away but sat down to perform the task of putting on his shoes
after prompt from mother. Raymond asked for help before starting task and mother said try it
yourself. Raymond had a hard time loosening his shoe laces and required verbal and physical
prompts from his mother but followed. Raymond tried to put on left shoe with both hands but
requires verbal and physical assistance to put foot in shoe and pull the shoe tongue from his
mother. Raymond transitions to the right shoe and needs assistance from his mother to loosen
laces. Raymond got the tip of his foot stuck in the shoe but with prompts from mother gets shoe
on with minimal signs of frustrations such as grunting. Raymond was observed cutting.
Raymond stabilized paper with left hand and moved paper with left hand while cutting. Both of Commented [SG2]: His L hand was pronated at first and
Raymond’s arms are in the air while cutting. Raymond holds scissor with correct grasp. he cut the paper on the table.
Raymond takes small cuts at the paper to cut out complex shapes. Raymond was observed
playing outside. Raymond communicated with individual and stated he wanted to play with
water toy. Supervising individual stated no but client persisted to show interest in the toy. Client
found the hose necessary for the toy and connected it without assistance. Raymond went to turn
on water and noticed the hose was not connected and did not have the right head to connect.
Raymond persisted to try but transitioned to playing with a basketball with other children when
prompted by a peer.
Supports/Strengths and Barriers/Limitations: Identify two supports/strengths and two
barriers/Limitations for each category. Please include reasoning for choice.

Client Factors Performance Skills &

Contextual Factors
Patterns

-Mental Function of -Motor skill of -Physical

Attention: Raymond is Endures: Raymond is Environment:
able to attend well to able to persist in Raymond lives in a
tasks even when they completing difficult or home filled with all the
are non-preferred task non-preferred tasks with supplies, toys, and tools
and only displays no sign of fatigue and necessary for him to
minimal signs of only minimal sign so develop and have a
frustration. frustration. successful life.
-Control of Voluntary
Supports/Strengths Movement: Gross
-Motor Skill of Moves: -Social Environment:
Motor Control:
Raymond does not Raymond has a very
Raymond does have
display any difficulty supportive social
any major problems or
pulling the heavy object environment consisting
difficult with the gross
of the hose where he of his immediate family
motor skills necessary
wanted it to be. and extended family.
for walking or playing.

-Control of Voluntary -Motor Skill of -Physical

Movement: Fine Manipulate: Raymond Environment:
Motor Control- has a hard time Raymond has a limited
Raymond has deficits manipulating objects physical environment
in fine motor control, such as his shoes, mainly consisting of his
which is displayed by clothing fasteners, etc. home.
his difficulties in the
Barriers/Limitations fine motor task of -Social Environment:
Raymond has a limited
writing, cutting, -Social interaction skill
social environment.
dressing with fasteners, of approaches/starts:
Raymond engages
etc. Raymond does not
socially with people he
approach or start
-Control of Voluntary knows such as his
conversations with
Movement: Eye Hand family but does not
people he does not know
Coordination-
and does not have friends
 Raymond has difficult outside of his family as engage with peer he
time completing tasks per mother’s report. does not know.
that require eye –hand
coordination which is
likely impacting FM
control in tasks.

Analysis of occupational performance:

Raymond demonstrates proficient gross motor skills and control necessary to get around his
home and community. Raymond is able to attend during class time with minimal support from
mother and siblings. Raymond is able to attend and complete non-preferred tasks such as putting
on his shoes with Max verbal and physical assistance from his mother. Raymond only displays
minimal signs of frustration with completing non-preferred tasks. Raymond has difficulty
completing several fine motor tasks such as brushing his teeth, dressing with fasteners/putting on
shoes, feeding with utensils, and writing/cutting tasks. As per mother’s report and observation
Raymond has a hard time manipulating task tools to successfully complete tasks. When cutting
Raymond compensates for lack of fine motor control by using gross motor muscles by lifting his
arms up and not having them down by his side. Raymond lacks the control to maneuver his
toothbrush to clean all of this teeth adequately. Raymond lacks the fine motor control to
manipulate shoes laces and the tongue of his shoe. Raymond has a hard time manipulating
utensil such as his knife to cut his food as per mother’s report. Raymond interacts well with
family members but does not communicate with peers as per mother’s report. Raymond does not
have frequent opportunities to communicate and interact with peers. Raymond would benefit
from skilled occupational therapy services to address his fine motor control necessary for
completion of the self-care tasks of teeth brushing, dressing, feeding, and school tasks. As well
as develop necessary social skills for peer interaction.

Intervention Plan

Problems Prioritized: Based on evaluation information, list top three problems/priorities

for intervention (i.e. Specific occupations for long term goals)
1. Social Participation with Peer

2. Brushing his Teeth

3. Dressing with Fasteners and putting on shoes

Based on evaluation data:

• Choose an organizing practice model (i.e. PEO, MOHO) that will help guide you in the
overall intervention process. Be specific and describe how this model would direct your
intervention
• Choose at least 2 (two) complementary OT models that will help guide you in the overall
intervention process. Be specific and describe how this model would direct your
intervention. List only those most pertinent.
 Practice How this practice model would direct your intervention (i.e. what would
Models you be looking for based on this model)

Organizing: PEO: I would utilize the PEO model for intervention because it takes into
account all aspects of Raymond. The PEO would facilitate me taking into
account his personal abilities and deficits, the supports and barriers to his
environment, and his desired occupations. This model will ensure I view
Raymond holistically and use a top-down approach to treatment.

Complementary Social Participation FOR: I would utilize the Social Participation FOR to coach
#1: Raymond it how to interact with his peers. This model helps locate aspects of
social interaction which needs to be address to promote successful interaction
outside of therapy. This model focuses on modeling positive social interaction
during therapy to support carry over outside of therapy. I would also use this
model to teach the mother how to support social interactions with peers to
support further incorporating into daily routines. With increased opportunity Commented [SG3]: Given the analysis of all the
and proper modeling social interaction skills can be built and implemented into difficulties he is having with motor skills, I would expect that
one of these would be a motor FOR.
daily life through the use of this model.

Complementary Strengths-Based FOR for ASD: This model is an excellent model to utilize in
#2: treatments with Raymond because it focuses on his strengths and not barriers.
Raymond has a lot of strengths which I would use as a foundation to build
occupational deficits. This model focus on developing the child’s autonomy,
competence, and relatedness which will be a strength now and in the future
when transitioning to adulthood. I would use this model by allowing Raymond
to feel in control of the situation by picking the order therapy task but
maintaining structure in an effort to build autonomy. I would build competence
by backward or forward chaining task to increase his mastery and feeling of
success. Lastly, I would build relatedness by facilitating positive and successful
social interactions with others.

Long Term Goals

#1: Within 6 months, Raymond will approach and start a conversation with a peer with no more
than 3 verbal prompts from mother/therapist in 2/3 opportunities. Commented [SG4]: What occupation?

#2: Within 6 months, Raymond will independently brush his teeth morning and night with no
more than 2 verbal prompts from mom to clean all his teeth 5/7 days a week.

#3: Within 6 months, Raymond will independently put on and tie his shoes with no more 2
verbal prompts from mother 5/7 days a week. Commented [SG5]: Might make this full body dress to
include fasteners
Student’s Name __Sarah Layton_________________________________________________________

Department of Occupational and

Recreational Therapies

Pediatric OSCE Documentation Grading Rubric

Competency Components Not Observed
High Level of
or Skill Adequate Skill
Skill
Performed Demonstrated
Demonstrated
Ineffectively
1. Demographic information, diagnosis, concerns, reason for X
referral
2. Occupational Profile X
• Includes occupational history, experiences, performance
patterns, interests, values, and needs & reason for seeking
services.
• Occupational performance strengths reported
• potential areas of occupation disruption reported
• Supports and barriers (context & environment) reported
• Parent’s Priorities & concerns for intervention reported
3. Observation of occupational performance X
• Actual performance data described from observation
4. Identifies two client factor supports/strengths X
• Appropriately identify two specific client factors (client
factors/performance skills) that are promoting occupational
performance(use OTPF language)
5. Identifies two performance skill/pattern X
supports/strengths
• Appropriately identify two specific performance skill/pattern
factors that are promoting occupational performance(use
OTPF language)
6. Identifies two contextual supports/strengths X
• Appropriately identify two specific contextual factors that are
promoting occupational performance(use OTPF language)
7. Identifies two client factor barriers/limitations X
• Appropriately identify two specific client factor that are
limiting occupational performance(use OTPF language)
8. Identifies two performance skill/pattern X
barriers/limitations
• Appropriately identify two specific performance skill/pattern
factors that are limiting occupational performance(use OTPF
language)
9. Identifies two contextual barriers/limitations X
• Appropriately identify two specific contextual factors that are
limiting occupational performance(use OTPF language)
10. Analysis of occupational performance X
• Obvious link between assessment data and occupational
performance deficits
• Performance analyzed and identified priorities supported
11. Priorities identified X
12. Organizing and complementary models used for X
intervention are appropriate and link to priorities
Student’s Name __Sarah Layton_________________________________________________________

13. Correctly writes two long term goals X

• Uses COAST/SMART format
• Outcomes emphasize function
14. Spelling/Grammar X
• Clearly communicates information
• Checks spelling and grammar
Final Grade: 91/100

Grading: 92/100 is earned if all skill items are marked “adequate skill
demonstrated”. One points will be added for each “high level of skill” marked.
However, the maximum number of points that can be earned for this component
of the OSCE is 100/100. One points will subtracted for each skill item marked
“Not observed/Performed ineffectively”.
Comments:

Only received a “Not observed/Performed ineffectively” because you should have

addressed motor deficits in more detail and including it as a guiding model.
Otherwise, very good job!