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occupational therapy fieldwork cheat sheet
Cutting goals
_____will snip with scissors in 4 out of 5 trials with ________ assist and _____% verbal cues to promote hand eye coordination for participation/ success in school setting. |
_____will cut out a circle in 4 out of 5 trials with ________ assist and _____% verbal cues to increase hand eye coordination for participation/ success in school setting. |
_____ will cut across a piece of paper in 4 out of 5 trials with ________ assist and _____% verbal cues to promote separation of sides of hands and hand eye coordination for optimal participation/ success in school setting. |
Assessments
PDMS-2 |
birth -72 months |
grasp and visual motor |
BOT-2 |
ages 4-21 |
Fine motor, manual & body coordination and strength |
VMI-6 |
ages 2-100 |
visual motor, visual perception and motor coordination |
Sensory Profile 2 |
ages 3-14 years and 11 months |
sensory processing, social interaction and praxis |
Levels of Assist
Independent |
requires no assistance of any kind |
Stand by assist |
supervision by one person for safe and effective task completion |
Min assist |
Patient requires no more than 25% of physical assistance to complete task |
Mod assist |
Patient requires 50% of physical assistance to complete task |
Max assist |
Patient requires 75% of physical assistance to complete task |
Total assist |
Patient requires more than 75%-100% of physical assistance by one or more person to complete task |
Writing goals
_________ will draw straight line capital letters ________ times in 4 out of 5 treatment sessions with ________ assist and _____% verbal cues for increased fine motor skills while maintaining a tripod grasp. |
________will write sentences using appropriate size and spacing ________ times with ______ assist and _____% verbal cues for increased fine motor skills while maintaining a tripod grasp. |
_____________ write letters of the alphabet with 90%+ accuracy for correct letter formation ________ times in 4 out of 5 treatment sessions with ________ assist and _____% verbal cues for increased dine motor skills and success in school setting. |
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Grasp goals
_____will open ___ hand to grasp a variety of size objects ________ times in 4 out of 5 treatment sessions with ________ assist and _____% verbal cues for increased grasp and release accuracy. |
_____will grasp a toy using BUE at midline in 4 out of 5 treatment sessions with ________ assist and _____% verbal cues for increased grasp and release accuracy. |
_____will trace first name with pencil/crayon folling correct letter formation with verbal prompts only, with 90% accuracy, 4/5 trials. |
CPT Codes
97530 |
Therapeutic activities |
97110 |
Therapeutic exercises |
97533 |
Sensory integration |
97150 |
Group therapeutic procedures |
97003 |
OT eval |
97542 |
W/C management, fitting and training |
97537 |
Community reintegration |
97140 |
Manual therapy |
97525 |
ADL retraining |
SOAP
S |
Subjective |
O |
Objective |
A |
Assessment |
P |
Plan |
Documentation
Child did something great |
accomplished, achieved, created, engaged in age appropriate... |
Participated |
engaged, explored, attempted, problem solved, performed |
Child needed help |
OT facilitated, OT encouraged, OT modified, OT guided, OT educated |
You modified activity |
adapted, graded, adjusted, OT presented multiple strategies for successful task completion |
Resources
OT toolbox |
OTdude |
Therapy fun zone |
Printpath.org |
OT plan |
Your therapy source blog |
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