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Autism Progress Note Sample

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aldinnan amin kadra

on 18 September 2014

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Transcript of Autism Progress Note Sample

Case Hx : Diagnosed with autism at Mercy's Hospital on 2005 after reported with a violent behaviour with other children and adults during class.

Family Hx: Paul currently lived with his mother, his father is a marine.

Medical Hx : Diagnosed with autism two years ago and attend physical & occupational therapy since then.

Social Hx: Currently attends a Local Education Authority (LEA) Special School. He is in a small class with eleven other children, also in Key Stage Two. Paul has had an educational statement for special needs since he was three years old.
Analysis of Occupational Performance



Treatment done with client:
Joint compression
Deep pressure
Vestibular input – (swinging on a blanket, rolling or jumping on therapy ball)
Hand manipulation
Buttoning, snapping


Plan of intervention:
(i) Family education. Family intervention.
(ii) Positive reinforcement in order to overcome behavioral problems.
(iii) ADL training for children.

Client’s Asset:
Highly motivated when encourage
Mother that very dedicated and helpful
Good financial support for family
Client’s Problems:
Easily frustrated.
Need verbal cues in certain activities
Improve fine motor according to his age.
Sensory stimulation.
Decrease maladaptive behaviour
Name: Paul
Age: 5 years old
Sex: Male
Race : Unknown
Religion: unknown
Marital status: single
Diagnose: fine motor delay,
sensory processing d/o
Reporting Period: 3/9/2008 – 5/9/2008
Service required:
Initial evaluation and assessment:
Behaviors problem ; not focus during activity.
Throwing himself on the floor.

After 3 months;
Have eye contact.
Attention in task up to 30 minutes.
Can focus in activity and complete the activity.
Writing more clear
Color within boundaries.
Still have problem in initiating dressing and bathing activity.Need redirection and verbal cueing in this activity.

Sensory processing skill
Can tolerance various types of texture, movement and activity.
Goals achieved:
Placing socks and shoes on correct feet.100% all the time.
Use functional grasps in writing, coloring, write name and drawing.
Dress UE & LL with minimal assistance80% all the time.
Continue goals:
Teach family to calm patient nervous system such as joint compressing, deep pressure, vestibular and proprioceptive input such as rolling, swinging and jumping.

Patient can bath himself with verbal cues, 80% all the time.Need cues to wash certain areas and in washing his hair.

Increase fine motor processing by demonstration of in hand manipulation such as buttoning and snapping with 80% accuracy all the time.Patient have problem in buttoning small button and pinch grasper in small object.Can be frustrated with verbal cues and encouragement to continue the task.
Client's Patterns
Role: A student at Local Education Authority (LEA) Special
Routines: 5 hour class from Monday-Wednesday and
3 hour class on Thursday & Friday.
Attend church every Sunday and
Visit his grandparent on the same day.
Habits: Sleep with bottle on his mouth.
Rituals: Catholic Christian.
Client’s Priorities and Needs: Practice fine motor and focus on
decreasing maladaptive behaviors.
Verbal cueing must be said thoroughly to child when he gets frustrated.
Avoid giving too much cueing, then he will get frustrated.

Education to family about ideas on how to help child to calm down when frustrated.
Performing ADL training such as dressing, bathing.
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