Plan of Care - Occupational Therapy

Student Name:
DOB: IEP Date:
District of Service:
Supervisor’s Name:
F81.9 Dev. disorder of scholastic skills, unspec
F82 Specific dev disorder of motor function
F84.0 Autistic disorder
F90.9 Attention deficit hyperactivity disorder unspec
F80.9 Cerebral palsy, unspecified
Q90.9 Down syndrome, unspecified
R27.9 Unspecified lack of coordination

ETR completed Yes or No Expected year _______

Areas of occupation in education	Sensory	Fine motor	Perception
Cognitive	Extra-curricular	Recess	Self-care

Min/ mon frequency	1:1	Group	Consult

Performance Skills
Sensory	Fine Motor	Perception
Proprioceptive	Scissors	Visual scan
Tactile	Cursive	Left to right
Vestibular	Grasp	Distance copying
Auditory	Bilateral	Reversals
Visual	Letter formation	Spatial orientation
Attention to task	Print	Visual boundaries
Behavior	Keyboarding
Pre-writing shapes
Cognitive	Recess	Self-Care
Follow direction	Socialization	Shoe tying
Sequencing	Motor planning	Clothing/fasteners
Attention to task	Behavior	Toileting
Dressing
Feeding
Extra-Curricular

Intervention Strategies/Performance Skills
Sensory	Fine Motor
Sensory breaks	Hand strengthening
Sensory diet	Hand development - wrist extension, hand separation, in-hand manipulation, finger isolation
Icon schedule
First, then schedule	Tool use: scissors, grasp, keyboarding
Brain gym	Tracing
Crossing midline	Range of motion
Strategies	Adaptive equipment
Eye-hand coordination
Hand dominance
Bilateral
Pre-writing shapes
Perceptual	Cognitive
Boundaries	Sequencing
Left edge alignment	Organization
Baseline orientation	Attention to task
Reversals	Pre Vocational Skills
Top/down	Functional strategies
Counter clockwise	Check off list
Oculomotor	Memorize cues, songs
Perceptual activities
Environmental Accommodations
Seating
Reduce distractions
Incline boards
Grippers

Comments:

Therapist implementing plan of care

Plans for periodic assessment/desired communication from treating therapist to evaluating therapist

Regular communication via phone & email	Every ________ months

Precautions/contraindications/specific problems

Seizure activity	Allergies	Medically fragile	District to district	Attendance issues
Comments/Other:

Anticipate Discharge

__________years	Next ETR	Determined after next review of strength/needs

Signature: _________________________________ COTA reviewed initials/date:_____________________

Revised 12/2015