CEBU VELEZ GENERAL HOSPITAL Department of Rehabilitation Medicine SECTION OF OCCUPATIONAL THERAPY Name of Pt: ________________________ Age/Sex: ___________________________

Diagnosis: __________________________ Address: ___________________________ Contact No.: ________________________ OT-in-charge: _________________________ OT Supervisor: ________________________ Rehab Doctor in-charge: ________________ Date Referred: ________________________ Date of Evaluation: _____________________

OCCUPATIONAL THERAPY PEDIATRIC INITIAL EVALUATION S: I. HPI: (In chronological order; paragraph form) Patient was born FT / PT via CS / NSVD / forcep extraction, cephalic / breech presentation to a then ___-year old G P (P A L M) mother at the hospital assisted by a doctor / midwife / nurse. G (gravid) = # of pregnancies irregardless of the outcome P = term pregnancies (37 wks) A (abortion) = either elective or spontaneous L (living) = represents # of children living M (multiple gestation at birth) Maternal history: o Diabetic o Hypertensive o Smoker o Alcoholic o Others: ______ (may include mothers lifestyle) Prenatal history: before delivery o Accidents o Illnesses o Vices o Check-ups o Interventions made Perinatal history: delivery to 4 weeks o Length of labor o Birth weight o Problems at birth, ancillary procedures conducted and interventions done o APGAR (description only) o Condition upon discharge including medications Postnatal history: 4 weeks to present o Accidents / illnesses o What / when was problem noticed?

o Diagnosis given and pts FUNCTIONAL STATUS o Why / when / where was consultation made? Relevant medical history o Immunizations given o Ancillary tests / dates / results o Indication of present medications if taken regularly/irregularly compliance Precautions and contraindications if necessary Previous / current therapy (include frequency, management received, and changes noted in FUNCTIONAL STATUS) Developmental Milestones o Pertinent to patients condition SKILLS Age Age expected achieved MOTOR DEVELOPMENT Hold head 4 mos Rolls over 5-6 mos Transfers objects 6 mos Sits alone 6-7 mos Stands alone 10-11 mos Walks alone 15 mos SPEECH/LANGUAGE DEVELOPMENT Coos 2-4 mos Babbles 4 mos Imitates non-speech sounds 10 mos Can say mama/ papa/ dada with meaning 10 mos Exhibits unintelligible jargon 1 year SOCIAL/EMOTIONAL DEVELOPMENT Look attentively at human face 1 mo Smiles at mirror image 4 mos Responds differently to strangers than to 7mos familiar persons

II. CONTEXTS A. Physical Contexts 1 or 2-storey house Any stairs / number of steps Sufficient space for locomotion and wheelchair accessibility (at home or in the community, as pertinent) Location and distance of rooms, especially of play room bedroom and bathroom Types and characteristics of task objects used during age-related occupations (e.g. toys, feeding utensils, tools and objects used in school, etc) Organization of the environment at home or at school Accessibility to rehab (how long does it take to go to rehab, mode of transportation) Accessibility to resources in the community (if applicable)

B. Personal Social Context Rank in the family General disposition or temperament (easy, difficult, slow-to-warm up, etc) with peers, family members, authority Childs daily routine Play history, including available toys, play equipment at home or in the neigborhood, interests and preferred activities, opportunities to play with other children Educational history including present school context (curriculum, student-teacher ratio, school hours, etc.) Primary caregiver and his/her attitude towards disability / therapy; abilities and willingness to carry out home instructions Other forms of support including finances O: I. OCCUPATION-BASED EVALUATION Perform Dynamic Performance Analysis on pertinent areas: A. Play Describe general behavior or response to play activities: o Unresponsive o Passive/shy o Irritable o Cooperative/playful o Hyperactive o Crybaby o With temper tantrums Age-appropriate/ age-inappropriate play level (according to Pratt/Piaget) o Exploratory (0-2 yrs) o Primary Circular Reaction (1-4 mos) o Reflexive (0-1 mo) o Secondary Circular Reaction (4-8 mos) o Symbolic (2-4 yrs) o Coordination of Secondary Schemes (9-12 mos) o Construction (4-6 yrs) o Tertiary Circular Response (12-18 mos) o Games with Rules (7-12 yrs) o Beginning of Thought (18-24 mos) B. Social Interaction Indicate age-appropriate / age-inappropriate personal-social-emotional skills. Refer BRIGANCE DIAGNOSTIC INVENTORY OF EARLY DEVLEOPMENT-REVISED Describe general social behaviour, including, but are not limited to: o Response to name-calling indicate if absent / consistent / inconsistent and then justify o Presence of stranger or separation anxiety o Eye contact (for patients 1 year and above) indicate if (+/-) meaningful eye contact or fleeting and then justify when this is observed (initiating conversation, etc) Level of social interaction (according to Parten)

Unoccupied play is the act of either standing in one spot or performing random movements seemingly without a goal to on outsider. It is commonly mistaken for the solitary play. Solitary play is when the child is independent of others. This aloneness is maintained by the amount of focus the child has on their activity and their engrossment with it. Onlooker play happens when the child watches the other children at play. They express interest and understanding with the activities going on around them but they do not engage in it. The interest in what the other children are doing is what makes this stage different Parallel play is what has been termed for when the child plays separate from the others but close to them and mimicking their actions. They play with similar toys and observe the children they are mimicking without the onlooker play type conversation Associative play involves social interaction with little or no organization. They are interested in the people surrounding them but not the activity they are doing. An example would be a group of preschoolers running around a play ground and laughing with no purpose or game. Cooperative play consists of social interaction in a group with a sense of group identity and organized activity. Little is seen in the preschool years because it requires organization. An example would be a game of freeze tag.

C. Self-Help Describe the childs performance based on observations; indicate if age-appropriate / ageinappropriate skills. Refer to BRIGANCE. Eating/feeding Dressing Bathing and grooming Toileting and hygiene D. Instrumental Activities of Daily Living Indicate level of experience o Describe the childs performance based on observations II. PERFORMANCE SKILLS, COMPONENTS AND CLIENT FACTORS When documenting your findings, prioritize the skills, components and client factors pertinent to the condition/case. A. Sensorimotor Skills, Sensory and Neuromuscular Functions 1. Range of Motion For psych: all joints of (state the side / extremity) are essentially WFL For phys dys: all joints of (state the side / extremity) are essentially WNL upon PROM, except for the ff: o State the joint, movement, the available ROM, and the cause of LOM (pain, contracture or skin adhesions) E.g., R shoulder flexion 0-80 2 to pain

Provide FUNCTIONAL JUSTIFICATIONS as necessary

2. Functional Muscle Testing Muscle tone of (B) UE/LE, trunk please separate entries o State whether normotonic, flaccid, hypotonic, hypertonic (spastic or rigid) Grade ms tone using the Modified Ashworth scale Modified Ashworth Scale: 0 = no increase in ms tone 1 = slight increase in ms tone, catch and release / min resistance at end of ROM 2 = more marked increase in ms tone through most of the ROM but affected parts easily moved 3 considerable increase, passive movt difficult Indicate which ms group has spasticity (flexors / extensors) Muscle strength of (B) UE / LE please separate entries o Functional description including resistance provided by objects / activity; state if there is weakness, difficulties noted, 3 or more justifications) Muscle bulk o Note any atrophy or hypertrophy noted and measure o Significant atrophy only if >2.5 cm or 1 inch 3. Gross Motor Skills a. Developmental Reflexes and Balance Reactions (+/-) Blecks Reflexes: o Moro o ATNR o STNR o Parachute o Neck righting o Step placement o Extensor thrust DTRs (illustrate) Pathologic reflexes o Babinsky o Wrist clonus o Ankle clonus o Hoffman (+/-) Balance Reactions: o Equilibrium Reactions: (+/-) in what positions and what directions o Righting reactions: (+/-) in what positions and what directions o Protective extension: (+/-) in what positions and what directions If age and capacities are beyond 11 mos, state as: Developmental Reflexes and Balance Reactions are integrated. b. Stationary and Locomotion Skills Grade as: Age-appropriate / Age-inappropriate then JUSTIFY

o Head Control: pull-to-sit, sitting, prone o Trunk Control: roll over, prone, (POE, POH), sitting o Pelvic Control: quadruped, kneeling, standing) o Developmental milestones (sensorimotor development) Balance and Tolerance o Sitting o Kneeling o Standing o Walking Grading Balance: 0 Absent 1 can assume or maintain 2 can assume and maintain 3 can assume, maintain, & weight shift 4 can assume, maintain, weight shift & can be challenged Tolerance : Poor 0-15 mins Fair 16-30 mins Good 31-45 mins

c. Advanced Gross Motor Skills Advanced GMS: refer to BRIGANCE. Describe performance of pertinent AGMS 4. Fine Motor Skills (R/L) Hand preference (2-4 y/o) (R/L) dominance (5-6 y/o) (R/L) handedness (7 y/o) (+, -, emerging) Voluntary Reach-Grasp-Carry-Release Patterns Gross and Fine Prehension Patterns Prehension Grade L R GROSS Cylindrical Spherical Hook FINE Lateral Tripod Pad-Pad Tip-Tip Opposition

Remarks

GRADE G F P A

DESCRIPTION Can assume, maintain, AND use Can assume AND maintain BUT cannot / has difficulty in use Can assume OR maintain, BUT with difficulty / needs assistance Cannot assume or maintain

For the following skills, specify which arm or hand (right, left or both)and if (+), (-) or emerging and provide FUNCTIONAL JUSTIFICATIONS for each components: ( ) Functional grip strength ( ) Functional pinch strength Control of Voluntary Movement Functions o Coordination state if (+) or (-, then describe the quality of movement. Provide FUNCTIONAL JUSTIFICATION Eye-hand coordination Arm-hand Bilateral symmetrical, asymmetrical and reciprocal coordination o ( ) Crossing the midline note trunk rotation or ability to isolate UE movement from trunk o ( ) In-hand manipulation finger-to-palm & palm-to-finger translation (with/without stabilization), shifting, simple and complex rotation (provide justification for each) o ( ) Dexterity state if G or P; then justify for dominant hand only Tool Use

For the following skills, state if age-appropriate or age-inappropriate and justify Pre-writing / writing skills o Include the pattern of grasp o Indicate level (lines / shapes that can be imitated, copied, or drawn) o Indicate quality of handwriting and coloring o Refer to BRIGANCE(C-3 Pre-handwriting, C-5 Forms) for skills expected at childs present age o e.g., able to copy cross independently, able to trace square with HOHA Pre-cutting / cutting skills o Refer to BRIGANCE (C-6 Cutting With Scissors) o Include the pattern of grasp o Indicate manner of cutting, quality of cutting, type of lines / figures and materials cut, deviations etc. o e.g., able to cut a 5-inch long thick line with minimal deviations, independently and without difficulty; able to hold bond paper (paper, fabric, boards etc.) with (L) hand while (R) hand uses mature grasp in manipulating scissors

5. Sensory Functions Grading: intact, impaired, or absent and justify

STIMULUS Visual threat Visual localization Visual tracking Auditory localization Auditory tracking

RESPONSE

6. Other Pertinent Findings Indicate if (+/-) for each relevant findings o Ambulatory aids o Devices used for feeding and/or defecation/urination i.e. NGT, PEG, Ostomies o Orthopaedic abnormalities o Lordosis/kyphosis o Presence of wounds, bruises, sores o Facial body asymmetry o Drooling (what position) secondary to ____. (mild, mod, max, profuse) o Head circumference in cm (normo, micro, macro) o Deformities ntoed (eyes, extremities, posture gait) If CP note the ff: cortical thumb or fisting, wrist flexion deformity, gait deviations (scissoring, crouch, limping gait, tiptoeing, etc), foot deformities, eye deviations (strabismus, nystagmus), synergies of UE and LE, splints, braces, etc If Down Syndrome, state physical features If Hydrocephalus and similar cases: uses of external devices such as VP shunt, measurement of skulls circumference B. Perceptual and Cognitive Functions 1. Sensory Integration Using the SENSORY HISTORY CHECKLIST, identify red flags and relate these to your clinical observation of behaviours that appear to be affected by probable Dysfunction in Sensory Integration, such as, but NOT limited to: o Presence of sensory avoiding/defensive behaviour o Presence of sensory seeking behaviours o Poor registration/response to stimuli o Shows hyperactivity and distractibility o Poor motor planning 2. Perceptual Skills (Applicable to children aged 6 yrs and above) Scoring: intact, impaired, absent and justify Perceptual Skills Test Items Body scheme Kinesthesia Visual perceptual o Visual Discrimination o Visual Spatial Relation o Visual Memory o Visual Sequential

Response

Memory o Visual Closure o Visual Figure-ground o Visual Form Constancy R/L discrimination Stereognosis

3. Cognitive Skills (+/-) orientation/awareness of self and the environment (+/-) imitation (specify whether verbal or motor) (+/-) identification and use of common object/s (specify what object/s) Concepts (refer to BRIGANCE) o Age-appropriate / age-inappropriate color concept (state the ability to match, sort, recognize and identify) and (name the specific colors) o Age-appropriate / age-inappropriate shape concept (state the ability to match, sort, recognize and identify) and (name the specific colors) o Age-appropriate / age-inappropriate body part/s concept (state the ability to recognize and identify) and (name the specific parts) o Age-appropriate / age-inappropriate quantitative concept (i.e. little/big, short/tall, etc.) o Age-appropriate / age-inappropriate directional/positional concept (i.e. close/open, top/bottom, right/left, etc) C. Socioemotional Functions and Communication Skills 1. Behavior a. Attention Span (for patients 1 year and above) duration of structure in structured and unstructured tasks. Grading: 3 to 5 minutes per year of a childs age is considered to be his/her average attention span. E.g. a 3 y/o child has a minimum attention of 9 mins, maximum of 15 o G the child reaches maximum number of minutes o F the child fall under the minimum-maximum range o P below the minimum time requirement b. Concentration (for patients 1 year and above) indicate level of distractibility, kind of distraction (visual or auditory), ability to refocus with or without cues/promts given (visual, verbal, physical) c. Impulse control (for patients 3 years and above) indicate ability to remain seated, grabbing, ability to wait for instructions, turn-taking skills, excessive or inappropriate verbalizations d. Activity / Frustration Tolerance (for patients 3 years and above) describe the response o the activity (such as disengagement from task, throwing tantrums, verbalizations, etc),ability to withstand trial and error activities, tolerance to perform complex activities, level of cues/prompts minimal, moderate, maximal) needed to return to task e. Other work behaviors (for patients 7 years and above and for moderate- or highfunctioning patients) such as planning and organization, attention to detail, problem solving.

2. Communication Skills Comprehension (+, -,emerging) ability to follow instructions; indicate # of steps and # of critical elements, medium of instruction (verbal and/or gestural) Expression (+, -,emerging) ability to indicate needs (verbal and/or gestural) Speech Level: (undifferentiated crying, differentiated crying, babbling, cooing, lallation, echolalia, expressive jargon, one-word sentence, multiword [___-word sentence], grammatically correct verbal utterances A: Integrate the results of your evaluation by: Identifying the pts strengths and weaknesses in a tabular form: STRENGTHS WEAKNESSES

Stating your hypothesized prognosis in play, self-help and school participation based from your findings noted during the interview, clinical evaluation, and medical prognosis (according to literature). o Pt has (good/guarded/poor) prognosis in (area) (performance, skills, and contexts) Determining your OT problem list by assessing which activity demands, contexts, performance skill deficits, missing performance components or client factors are limiting occupational performance OT PROBLEM LIST 1. Pt has difficulty in (Performance Area) secondary to (which activity demands, contexts, performance skill deficits, missing performance components or client factors are limiting occupational performance) associated with / secondary to (MEDICAL DIAGNOSIS)

P: 1. Problem Long Term Goal The acceptable form: To improve (AREA): Short Term Goals Patient will be able to (description of specific steps of the functional activity expected of the patient) given (conditions/criteria, such as level of independence, materials/equipment to be used, etc) after (# of sessions). POA: TUS: BMTs: EMTs: TUA: o Preparatory o Purposeful

RECOMMENDATIONS: Give specific recommendations including referral to other service providers (physician, PT, SP, psychology, social worker, dietician, etc)

Prepared by: _________________ OT-in-charge

Noted by: ______________ OT Clinical Supervisor