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Occupational Therapy Cheat Sheet by

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.
 

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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